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A   TREATISE 

ON 

BRIGHT'S 

Disease  of  the  Kidneys 

ITS  PATHOLOGY,  DIAGNOSIS,  AND  TREATMENT. 


WITH   CHAPTERS    ON    THE   ANATOMY   OF  THE    KIDNEY,    ALBU- 
MINURIA, AND  THE  URINARY  SECRETION. 


BY 

HENRY  B.  MILLARD,  M.D.,  A.M. 


tDitl)  Numerous  ©riigiual  SUustrations. 


NEW    YORK: 

WILLIAM   WOOD   &   COMPANY, 

56  AND  58  Lafayette  Plaoe, 
1884. 


COPYEIGHT,  1883,  BY 

WILLIAM  WOOD   &  COMPANY 


TROWS 
ND  BOOKBINDING  COMPANV 
NEW  YORK 


TO 

Dr.  J.  M.  CHARCOT 

PROFESSOR  IN  THE  FACULTY  OF  MEDICINE,  PARIS ;  PHYSICIAN 

TO  THE  SALPETRIERE ;    MEMBER  OP   THE  ACADEMY 

OF  MEDICINE;    OFFICER  OF  THE  LEGION 

OF  HONOR;   ETC.,  ETC. 

AND  TO 

Dr.  M.  DEBOVE 

PHYSICIAN  TO  THE  BIC^TRE  AND  PROFESSOR  AGREGE  IN  THE 
FACULTY  OF  MEDICINE 

THIS  VOLUME 

IS,  WITH  THEIR  PERMISSION,  DEDICATED 

BY  THE  AUTHOR 

AS   A   TRIBUTE    OF    RESPECT   FOR    THEIR  PROFOUND   ATTAIN- 
MENTS IN  MEDICAL  SCIENCE,  AND  AS  A  SLIGHT 
ACKNOWLEDGMENT  OF  MANY  ACTS 
OF  KINDNESS. 


PREFACE. 


I  HAVE  only  to  say  of  this  volume  that  it  is  the  result 
of  the  experience  of  nearly  twenty-six  years  of  hospital 
and  extensive  private  practice,  and  of  several  years' 
study  in  the  laboratory,  of  pathological  and  healthy 
kidneys  of  men  and  animals.  The  illustrations  were 
all  drawn  by  myself  from  kidneys,  with  the  exception 
of  Figures  1,  2,  and  7,  which  are  taken  from  other  au- 
thors, and  4,  5,  6,  and  12,  which  were  drawn  for  me  from 
my  own  preparations. 

In  perusing  the  works  of  many  writers  upon  nephritis, 
I  may  in  some  instances  unconsciously  have  incorpo- 
rated their  ideas  without  according  due  credit.  I  have 
endeavored,  however,  carefully  to  fulfil  all  obligations 
of  this  kind. 

As  I  have  shown  in  the  context,  the  term  Bright' s 
disease,  as  understood  by  Bright  himself,  does  not 
comprise  every  condition  of  nephritis,  but  as  most  of 
the  conditions  I  have  described  are  generally  understood 
as  belonging  to  Bright's  disease,  I  have  given  my  work 
this  title,  though  the  nomenclature  is  by  no  means 
exact.  I  have  usually  employed  instead,  throughout 
the  book,  the  word  nephritis. 

I  have  used  exclusively  the  word  albumin  instead  of 


VI  PEEFACB. 

albumen,  althougli  tlie  termination  en  is  generally  used 
by  medical  writers.  The  word  albumen,  is,  however, 
simply  the  Latin  word  meaning  the  "white  of  the 
Qg^r  though  it  is  applied  to  every  variety  of  albumin  ; 
the  latter,  however,  represents  the  proximate  princi- 
ple, and  I  believe  chemists  now  generally  distinguish 
the  two  by  the  terminations  en  and  in.  In  Watts' 
"Dictionary  of  Chemistry,"  '  the  most  important  work 
of  the  kind  in  English,  the  termination  in,  is  exclusively 
used. 

Where,  however,  I  have  quoted  from  other  authors,  I 
have  not  felt  justified  in  changing  their  spelling. 

My  work  has  been,  at  least,  conscientiously  perform- 
ed, and  with  an  earnest  desire  of  adding  to  the  knowl- 
edge*and  therapeutics  of  the  subject  of  which  it  treats. 


H.  B.  MILLARD. 


4  East  Foety-fikst  St.  ,  New  York, 
November  1,  1883. 


^Longmans,  Green  &  Co.,  London,  1870. 


TABLE  OF  CONTENTS. 
PAR  T    I. 

CHAPTEE  I. 

PAGE 

General  Anatomy  of  tlie  Kidney 1 

CHAPTER  n. 
The  Epithelia  of  the  Urinary  Tubules 6 

CHAPTEE  in. 
The  Endothelia  of  the  Urinary  Tubules , 18 

CHAPTEE  TV. 
The  Connective  Tissue  of  the  Kidney 23 

CHAPTEE  V. 
The  Circulation  of  the  Kidney = 25 

CHAPTEE  VI. 

Nerves  of  the  Kidney •...,,.....     28 

CHAPTEE  Vn. 

Nature  and  Sources  of  the  Urinary  Secretion  and  Extractives 29 


VIU  CONTENTS, 


CHAPTEE  Vin. 

PAGE 

The  Significance  of  the  Existence  or  Non-existence  of  Albumin  in 
the  Urine,  and  the  General  Conditions  of  its  Occurrence  in 
Health  and  Disease 37 


CHAPTEE  IX. 

The  Tests  for  Albumin  in  the  Urine 4:9 

CHAPTEE  X. 

The  Importance  and  Significance  of  Urinary  Casts 61 

CHAPTEE  XI. 

Nature  and  Mode  of  Formation  of  Urinary  Casts 65 

CHAPTEE  Xn. 

General  Directions  for  Examining  the  Urine  for  Casts  and  Kidney 

EpitheHa 73 

CHAPTEE  Xm. 

Of  Nephritis 75 

CHAPTEE  XIV. 

Croujpous  Nephritis. — Characteristics. — Acute  Croupous  Nephritis     79 

CHAPTEE  XV. 

Chronic  Croupous  Nephritis 92 

CHAPTEE  XVI. 

Suppurative  Nephritis 114 

CHAPTEE  XVII. 

Catan'hal  or  Interstitial  Nephritis 117 


CONTENTS.  IX 

CHAPTEE  XVin. 

PAGE 

Actite  and  Clironic  Interstitial  Nephritis 119 

CHAPTEE  XIX. 

Nephritis  without  Albuminuria 141 

CHAPTEE  XX. 

Chronic  Interstitial  Nephritis  (continued) 155 


FART  //.—Treatment. 

CHAPTEE  XXI. 

The  Treatment  of  Acute  Nephritis 163 

CHAPTEE  XXII. 
Treatment  of  Chronic  Nephritis 203 

CHAPTEE  XXIII. 

Treatment  of  Chronic  Interstitial  Nephritis 205 

CHAPTEE  XXIV. 

Treatment  of  Chronic  Croupous  Nephritis 231 

CHAPTEE  XXV. 

Treatment  of  Suppurative  Nephritis ,.,..... 238 

APPENDIX 239 

INDEX.  ....................................................   241 


LIST  OF  ILLUSTRATIONS. 


PAGE 

Fig.  1. — DiAGKAM  SHOwmo  the  Course  and  Variations  of  the 

Renal  Tubules 4 

Fig.  2.  — Diagram  of  the  Vareettes  of  Epithelia 7 

Fig.  3. — Transverse  Section  of  the  Cortical  Substance  op  Dog's 

Kidney.     (500  diameters. ) 8 

Fig.  4. —Convoluted  Tubule  froji  the  Kidney  of  a  Rabbit. 
(Longitudinal  section— magnified  1,200  diameters.) — Nucleated 
columnar  epitlielium,  showing  the  rods  ;  endothelia  ;  interstitial 
connective  tissue,  producing  the  basement  layer 13 

Fig.  5. — Convoluted  Tubule  from  a  Human  Kidney  affected 
with  Acute  Catarrhal  (Interstitial)  Nephritis.  (Ohlique 
section — magnified  1,200  diameters.) — Inflammatory  corpuscle, 
sprung  from  the  division  of  an  epithelium  ;  cluster  of  inflamma- 
-tory  corpuscles,  sprung  in  the  same  manner  ;  rods  of  cuboidal 
epithelia,  still  recognizable  ;  endothelia,  increased  in  size  and 
number 16 

Fig.  6. — Convoluted  Tubule  from  a  Human  Kidney  affected 
WITH  Chronic  Catarrhal  (Desquamative)  Nephritis.  (Ob- 
lique section T— magnified  1,200  diameters.) — Calibre,  widened  by 
loss  of  the  epithelia ;  endothelia,  increased  in  size  and  number  ; 
interstitial  fibrous  connective  tissue,  with  augmented  plastids  ...     20 


Xll  LIST   OF   ILLUSTRATIOlSrS. 

PAGE 

Fig.  7. — (From  Heitzmann.) — Boundary  Line  bett^een  the  Cor- 
tical AND  Pyramidal  Substance  of  the  Kidney  of  a  Dog. 
Blood-vessels  Injected. — Branch  of  renal  artery  ;  prolonga- 
tion of  the  cortical  substance  ;  tuft ;  bundle  of  straight  tubules ; 
origin  of  the  vasa  recta  from  the  capillaries  of  the  cortical  sub- 
stance :  bundle  of  vasa  recta.     (Magnified  100  diameters.) 26 

Fig.  8.— Hyaline  Casts.     (500  diameters. ) 63 

Fig.  9.— Mucous  Casts.     (500  diameters.) 63 

Fig.  10. — Acute  Croupous  N'ephritis  showing  Exudate. — Lon- 
gitudinal section  of  tubule,  showing  droplets  of  exudate.  (500 
diameters. ) 65 

Fig.  11. — Acute  Croupous  Nephritis. — Longitudinal  section  of  con- 
voluted tubule,  showing  formation  of  casts,  endothelia  etc.  (500 
diameters. ) 66 

Fig.  12. — Convoluted  Tubule  from:  a  Human  Kidney  affected 
■WITH  Acute  Croupous  ISTEPiiRms.  (Oblique  section — magni- 
fied 1,200  diameters.) — Hyaline  cast;  swollen  and  disintegrated 
epithelia  participating  in  the  formation  of  the  cast ;  wreath  of 
endothelia  ;  interstitial  connective  tissue 69 

Fig.  13. — Various    Forms  and  Kinds  of   Casts.      (Magnified  500 

diameters. ) 71 

Fig.  14. — Acute  Croupous  Nephritis. — Transverse  section  of  cor- 
tical substance,  showing  cloudy  swelling  of  epithelia.  (600 
diameters. ) 87 

Fig.  15. — Convoluted  Tubule  from  a  Human  Kidney  affected 
wt^th  Acute  (Interstitial)  Nephritis.  (1,200  diameters.) 
Same  as  Fig.  5 88 

Fig.  16. — Suppurative  Nephritis. — Epithelia  and  masses  of  living 
matter,  some  homogeneous  and  some  having  direerentiated  into 
inflammatory  corpuscles ;  shining  lumps  of  matter  and  inflam- 
matory corpuscles  ;  epithelium  dividing  ;  tubule,  with  granular 


LIST   OF   ILLUSTRATIOlSrS.  Xlll 

PAGE 

matter  greatly  enlarged  and  epithelia  enormously  swollen ; 
tubules,  witli  endothelia  and  broken-down  epithelia  and  granu- 
lar matter;  tubule  filled  with  pus  corpuscles;  epithelia:  the 
nuclei,  and  granular  matter  undergoing  transformation  into  shin- 
ing lumps ;  thickened  connective  tissue.  (Transverse  section, 
magnified  500  diameters. ) 90 

Fig.  17.— (Three  illustrations.) — A,  Chronic  Croupous  Nephritis — 
Straight  Tubule. — Granular  swelling  of  the  epithelia,  showing 
rods  and  reticular  structure.     (Magnified  1,000  diameters.) 

B,  Fatty  Degeneration  of  the  Kidney. — Cross-section  of 
convoluted  tubule.  Cloudy  swelling  of  epithelia,  showing  rods 
and  fat  granules.  Connective  tissue  thickened.  (Magnified  600 
diameters.) 

C,  Chronic  Croupous  Nephritis  with  Waxy  Degenera- 
tion, showing  rods  rather  enlarged.  Cross-section  of  ascending  tu- 
bule.   A,  droplets  of  waxy  exudation.     (Magnified  600  diameters.)  105 

Fig.  18. — Chronic  Croupous  Nephritis. — Cross-section  of  convoluted 
tubule  filled  with  nuclei,  granular  matter  from  broken-down 
epithelia,  and  indifferent  elements  ;  granular  cast  surrounded  by 
endothelia  ;  homogeneous  lumps  of  matter  formed  from  the  nuclei 
of  the  epithelia;  hyaline  cast  surrounded  by  endothelia  ;  epithe- 
lia converted  into  amyloid  or  waxy  corpuscles  ;  widened  struc- 
tureless membrane  ;  atrophied  tuft ;  space  between  capsule  and 
tnft  filled  with  connective  tissue  ;  thickened  capsule,  etc.  (Mag- 
nified 500  diameters.) 106 

Fig.  19. — Fatty  Degeneration  of  the  Kidney — High  Degree 
(Large  White  Kidney) — Chronic  Croupous  Nephritis. 

Spaces  greatly  widened.  — Fatty  cast ;  broken-down  epithelia, 
showing  fat  globules  ;  fat  globules  in  the  connective  tissue  ;  endo- 
thelia ;  nuclei  of  epithelia,  some  having  undergone  the  fatty 
change  ;  inflammatory  C/orpuscles  ;  tubule  with  granular  matter ; 
epithelia  undergoing  the  fatty  change  ;  epithelia  partly  broken 
down  or  showing  fatty  change.     (Magnified  500  diameters.) 107 


XIV  LIST   OF   ILLrSTEATIONS. 

PAGE 

Fig.  20.  — Waxt  Degeneration  of  the  Kidney — Chronic  Croijpoxjs 
Nephritis. — Waxy  cast;  capillary  with  waxy  walls;  medullary 
rays  with  iucipient  waxy  walls  ;  artery,  transverse  section  in  waxy 
degeneration  ;  epithelia  and  nuclei,  part  undergoing  waxy  change. 
(Magnified  500  diameters. ) 110 

Fig.  21. — Chronic  Croupous  Nephritis. — Columnar  epithelia,  show- 
ing cloudy  swelling ;  tuft  full  of  shining  granules ;  convoluted 
tuhule  filled  with  a  mass  of  hyaline  and  granular  matter,  (Mag- 
nified 500  diameters.) Ill 

Fig.  22.— Suppurative  Nephritis  (Abscess  of  Kidney). — Convoluted 
tubule,  filled  with  pus  corpuscles  and  lined  by  endothelia; 
broken-down  epithelia ;  tubuli  nearly  obliterated ;  pus  corpus- 
cles ;  increased  and  greatly  augmented  nuclei ;  inflammatory  cor- 
puscles ;  tubule  with  nearly  unchanged  epithelia.  (Magnified 
500  diameters.) 115 

Fig.  23. — Pus  Corpuscles,  Epithelia  from  the  Straight  and  the 
Convoluted  Tubules  and  Pelvis  of  the  Kidney.  (Magnified 
500  diameters. ) 153 

Fig,  24, — Cirrhosis  op  the  Kidney — High  Degree. — Striated  and 
hypertrophied  connective  tissue  ;  tuft  striated  and  enveloped  in 
connective  tissue  ;  tubule  converted  into  connective  tissue  ;  com- 
pressed and  shrunken  tuft ;  thickened  capsule,  etc.  (Magnified 
500  diameters. ).,,,.,, 159 


BRIGHT'S  DISEASE  AND  ALBUMINURIA. 


PART  I. 


CHAPTER  L 

THE  GEJnSRAL  ANATOMY  OF  THE  KIDNEY. 

That  what  I  have  to  sslj  upon  the  pathology,  diagnosis, 
and  treatment  of  nephritis  (Bright' s  disease)  may  be 
quite  clear,  I  may  be  permitted  to  map  out  and  briefly 
describe  the  region  in  which  are  situated  the  lesions 
which  exist  in  this  malady.  This  is  necessary  to  the 
general  reader,  because  few  who  do  not  make  pathology 
and  histology  a  special  study,  are  perfectly  familiar  with 
or  can  call  at  once  to  mind  the  minute  anatomy  of  the 
kidney. 

With  the  general  form  and  position  of  the  kidney  we 
are  familiar  enough  to  make  it  unnecessary  to  dwell 
upon  them,  simply  stating,  as  a  guide  in  autopsies,  the 
average  normal  weight  of  the  organ  to  be  between  four 
and  five  ounces. 

It  is  covered  by  a  dense,  closely  adherent  capsule,  and 
its  bulk  is  constituted  by  masses  of  tubules  arranged  in 
a  certain  order,  connective  tissue,  glomeruli,  and  blood- 
vessels, from  one  portion  of  which  the  nutrition  of  the 
kidney  is  derived,  and  from  the  other  most  of  the  con- 
stituents peculiar  to  the  urine  are  eliminated. 
1 


2  bright' S   DISEASE. 

The  whole  kidney  is  diAdded  into  two  principal  re- 
gions, the  cortical  and  medullary  ;  the  latter,  again, 
into  the  zone  of  limitation  or  marginal  region,  and  the 
papillary  region.  The  cortical  region  is  most  vascular, 
and  contains  many  thousands  of  small  bodies,  about 
ij-ff  to  ^^0  inch  in  diameter,  known  as  the  Malpighian 
bodies.  Each  of  these  bodies  consists  of  a  congeries  of 
blood-vessels,  from  0.02  to  0.03  mm.  in  diameter,  and  ar- 
ranged in  two  main  lobes,  contained  in  a  membranous 
sac,  known  as  "Bowman's  capsule."  This  congeries  of 
blood-vessels  is  composed  of  a  number  of  small  arteries, 
which  are  a  continuation  or  blossoming  of  a  small  ar- 
tery proceeding  from  an  interlobular  artery,  emptying 
into  Bowman's  capsule  at  a  point  nearly  opposite  the 
neck  of  the  capsule,  and  known  as  a  vas  afferens ; 
the  tuft  is  known  as  a  Malpighian  tuft  or  glomerulus  ; 
it  subdivides  into  seven  or  eight  arteries.  These  reunite 
to  form  a  vessel  known  as  a  vas  efferens,  which  emerges 
from  the  capsule  at  a  point  closely  adjoining  that  which 
the  vas  afferens  enters. 

The  convolutions  of  the  tuft  form  the  lobules,  one  be- 
ing slightly  larger  than  the  other  ;  they  are  both  covered 
by  a  very  thin  layer  of  connective  tissue  ;  this  is  reflected 
upon  and  forms  the  lining  of  the  capsule.  The  whole 
surface  of  this  delicate  membrane  is  covered  by  a  flat 
epithelial  layer  whose  functions  I  shall  hereafter  allude 
to.     The  glomerulus  is  not  adherent  to  the  capsule. 

From  the  blood  thus  introduced  into  Bowman's  cap- 
sule, certain  elements,  mostly  aqueous,  are  passed  out 
into  the  capsule,  and  hence  arises  the  necessity  of 
another  outlet  than  the  vas  efferens ;  this  outlet  is  the 
commencement  of  an  uriniferous  tubule  ;  it  commences 
as  a  constricted  neck,  which  quickly  dilates  into  a 
crooked  tube  {tubulus  contortus).  This,  with  many 
windings,  runs  toward  the  medulla,  in  reaching  which 
it  becomes  suddenly  attenuated,  and  descends  straight 


AXATOMY    OF   THE   KIDNEY.  3 

down,  forming  the  descending  branch  of  a  curve  known 
as  '^Henle's  loojp^  In  the  region  of  the  cortex  it  de- 
flects from  the  medullary  ray,  and  is  known  as  an  ir- 
regular tubule.  It  then  becomes  convoluted,  and  again 
forming  a  convoluted  tubule,  of  the  second  order,  its  con- 
vexity being  directed  toward  the  surface  of  the  kidney, 
and  empties  by  the  junctional  part  into  a  collecting 
tubule  ;  this  latter  runs  in  a  straight  direction  toward 
the  papilla.  AYhen  several  of  these  tubes  have  reached 
the  papilla  they  coalesce.  A  number  of  fascicles  of  col- 
lecting tubules,  constitut'mg  the  7?i€duUar  2/  ray,  or  pyra- 
mid of  Ferrein,  form  a  cone-like  body,  the  base  looking 
toward  the  surface  of  the  kidney.  These  cone-like  bod- 
ies are  produced  by  the  union  of  the  tubuli  uriniferi 
at  about  the  beginning  of  the  zone  of  limitation  ;  they 
reunite  just  above  the  papilla,  forming  the  cone.  A 
number  of  primitive  cones  form  the  pyramids,  or  ren- 
culi ;  they  have  a  bottle-shaped  appearance,  owing  to 
the  space  between  what  would  represent  the  junction  of 
the  neck  and  body  of  the  bottle.  These  pyramids  are 
known  as  i\\Q  pyraonids  of  MalpigM,  or  medullary  pyr- 
amids. There  are  from  ten  to  eighteen  of  these,  sep- 
arated from  each  other  by  the  prolongations  of  the  cor- 
tex known  as  the  columns  of  Berlin  ;  the  apex  of  these 
pyramids  forms  a  papilla  which  projects  into  the  calices, 
these  in  turn  being  formed  by  the  branching  and  sub- 
divisions of  the  pelvis,  the  latter  being  a  basin  formed 
by  the  expansion  of  the  ureter. 

The  formation  and  course  of  an  uriniferous  tubule  is 
shown  by  Fig.  1.    . 

The  changes  of  an  independent  uriniferous  tubule, 
from  its  commencement  at  Bowman's  capsule  to  the  time 
it  enters  into  a  medullary  ray,  are  numerous,  undergo- 
ing many  variations  in  direction  and  diameter.  The 
diameters  of  the  tubules  in  an  adult  vary  from  -^  to 
^\-^  of  an  inch.     The  space  between  the  medullary  rays 


bright' S   DISEASE. 


Fig.  1. — Diagram  showino  the  Course  and  Variations  of  the  Renal  Tubules.  After 
Ivleiii  and  Smith  (modified). — A,  Cortex  limited  on  its  free  surface  by  the  capsule ;  a,  subscapsu- 
lar  layer  not  containing  Malpighian  corpuscles ;  B,  boundary  layer ;  C,  medullary  substance, 
or  papillary  layer ;  1,  Bowman's  capsule ;  2,  proximal  convoluted  tubule ;  3,  descending  limb 
of  Henlo's  loop  ;  4,  the  loop  proper  ;  5,  ascending  limb  of  Henle's  loop  ;  6,  the  irregular  tu- 
bule, and  7,  the  intercalated  tubule,  constituting  the  distal  convoluted  tubule  ;  8,  junctional 
tubule ;  9,  10,  straight  collecting  tubule  of  medullary  ray  and  boundary  layer ;  11,  collecting 
tubule  of  papillary  part. 


ANATOMY   OF   THE   KIDNEY,  O 

in  the  cortical  substance  is  known  as  the  labyrinth  ;  it 
is  here  that  the  Malpigliian  bodies  and  the  tubidi  con- 
tortl  are  found. 

Bowman's  capsule  may  be  regarded  as  the  commence- 
ment of  the  uriniferous  tubule.  The  wall  of  each  tubule 
is  formed  of  a  delicate  membrane,  or  tunica  propria  ; 
this  is  absent  in  the  ductus  papillaris. 

Until  a  comparatively  recent  time,  this  membrane  has 
been  regarded  as  wholly  homogeneous  and  structure- 
less. Ludwig  shows,  however,  that  "though,"  in  his 
own  language,  "  this  is  as  clear  as  glass,  elastic,  a  nu- 
cleus can  occasionally  be  brought  to  view."  See  Chap- 
ter III. 


CHAPTER  II. 

THE  EPITHELIA  OF  THE  URESTAEY  TUBULES. 

The  membrane  of  Bowman's  capsule  and  its  neck  is 
continuous  ;  but  at  tlie  commencement  of  the  convo- 
luted tubule  it  changes.  Here  the  epithelia  are  com- 
posed of  a  clouded  mass  of  nucleated  protoplasm.  The 
epithelial  pulp  is  only  loosely  attached  to  the  basement 
membrane. 

R.  Heidenhain  first  called  attention  to  minute  granu- 
lations in  the  epithelia  in  certain  of  the  tubules  of  ani- 
mals which  he  called  stabchen,  having  a  long  axis  di- 
rected toward  the  lumen,  these  epithelia  being  known 
as  bacillated  or  rod-like  epithelia. 

As  the  tubules  undergo  various  changes  in  their  caliber, 
direction,  and  form,  so  do  the  epithelia  lining  them  vary. 
The  convoluted  tubules  of  the  first  and  second  order, 
the  ascending  and  descending  portions  of  the  narrow  tu-' 
bules,  are  lined  by  polyhedral  or  cuboidal  epithelia  ;  as 
the  ascending  and  descending  portions  of  these  become 
narrower,  the  epithelia  become  flat.  At  the  commence- 
ment of  the  collecting  tubules  they  are  lined  with  cu- 
boidal epithelia  which  soon  become  columnar,  and  in  the 
lower  portions  they  are  distinctly  imbricated.  The  form 
and  structure  of  the  various  epithelia  of  the  kidney  are 
shown  in  the  following  figure  from  Heitzmann.' 

As  the  article  is  pertinent  to  the  subject  now  under 
consideration,  I  subjoin  here  portions  of  a  paper  written 

'•Microscopical  Morphology  of  tlie  Animal  Body  in  Health,  and  Disease. 
C.  Heitzmann.     New  York :  1883. 


EPITHELIA   OF    THE   TITBULES. 


by  me  and  published  in  the  Neio  York  Journal  of 
Medicine^  June,  1882,  treating  also  of  certain  changes 
the  result  of  intiammation,  entitled,  "  Researches  in  the 
Minute  Anatomy  of  the  Kidney."  ' 

R.  Heidenhain'^  was  the  first  to  call  attention  to  the 
presence  of  a  peculiar  rod-like  or  bacillated  structure 


CVj 


Fig.  % — Diagram  of  the  Varieties  of  Epithelia. — i^,  flat  epithelia  in  front  view;  S, 
same  in  side  view  ;  Cu.  cuboidal  epithelia  ;  Co.  columnar  epithelia  in  side  view ;  T,  columnar 
epithelia  in  top  view  ;   Ci,  ciliated  columnar  epithelia  ;  5,  bacillated  columnar  epithelia. 

existing  in  the  urinif erous  tubules.  He  found  this  struc- 
ture in  convoluted  tubules,  in  the  ascending  portions  of 
the  looped  tubules,  and  in  the  intercalated  tubules  of 
the  kidneys  of  mammals. 

According    to    his  view,  the  rodlets  (stabchen)  are 
plainly  visible  in  the  outer  portions  of  the  epithelia — 

1  Read  before  the  New  York  Medico-Chirurgical  Society,  May  9,  1882. 
^  "  Mikrosk.    Beitriige    zur  Anat.   und   Physiologie    der   Nieren :  "    Max 
Schultze's  Arch.,  f.  mikr.  Anat.,  10  Bd  ,  1874, 


8  beight's  disease. 

that  is,  in  those  portions  lying  next  the  connective  tis- 
sue, and  he  sometimes  saw  in  torn  epithelia  the  rods 
isolated.  The  same  observer'  also  first  demonstrated 
with  accuracy  that  the  secretion  of  the  salts  is  per- 
formed only  in  the  tubules,  in  accordance  with  the  views 
maintained  by  Bowman.  Char- 
cot ^  deduces  from  the  experiments 
of  Heidenhain  with  indigo-blue 
the  conclusion  that  the  secretion 
or  elimination  of  this  coloring 
matter  takes  place  only  in  those 
portions  of  the  tubuli  uriniferi 
which  are  covered  by  the  epithelia 
having  the  rods  (epithelium  a 
batonnets).  Whether  the  secre- 
FiG.  3.-C0BTICA1  Substance  OF  tiou  of  the  specific  principles  of 

Dog's  Kidney — Transvekse  Sec-  .  it-  •      i 

HON— Blood  Vessels  Injected.—    the  UriUe  takeS  plaCe  lU    preClSelV 
A,   tuft:  B,    capsule;    C,    flat  epi-  o       i   •  i  •  • 

theiia;  D,  convoluted  tubule;  E,  the  Same  fashiou  as  the  elimmatiou 

straight  collecting  tubule  ;    F,   as- 
cending limb  of  narrow  tubule  ;  G,   of  coloring  matters,  he  regards  as 

descending  limb  of  narrow  tubule ;  o  >  o 

H,  irregular  tubule :  L  »a,sa  recto,  imposslble   of   demoustratlou  ex- 

Mi^nified  500  diameters.  ^ 

perimentally. 
In  a  late  monograph  \>j  Charcot,  Legons  sur  les  Con- 
ditions  Pathogeniqices  de  V Albuminurie,  Paris,  1881, 
he  regards  the  tubuli  contorti  and  the  loops  of  Henle, 
particularly  the  ascending  branches  of  the  loops,  as 
the  real  glandular  part  of  the  kidney.  "They  are," 
he  says,  "lined  by  an  epithelium,  thick,  granulated, 
cloudy — in  a  word,  glandular.  They  are  enveloped  in 
all  parts  by  a  dense  capillary  network,  bathed,  like 
themselves,  in  a  lymphatic  fluid."  "  These  parts  seem, 
then,  in  some  respects,  designed  for  the  selection  and 
concentration  of  the    specific  principles  of  the  urine, 

'  "  Versuche  iiber  den  Vorgang  der  Harnabsonderung  :  "  Pfltiger's  Archiv, 
9Bd.,p.  1.,  1874. 

^  Charcot  on  BrigM's  Disease,  translated  by  Millard,  p.  28,  New  York, 
1878. 


EPITHELIA    OF   TPIE   TUBULES.  9 

urea,  and  uric  acid ;  it  is  iu  these  parts,  no  doubt,  that 
is  formed  the  hippuric  acid,  which  does  not  pre-exist  in 
the  blood." 

Heidenhain,  however,  did  not  associate  the  rods  with 
the  process  of  secretion,  for  he  observed  a  similar  struc- 
ture also  in  the  smaller  ducts  of  the  parotid  and  sub- 
maxillary glands,  the  same  formation  in  the  latter 
structure  being  already  known  to  Henle  and  Ptiiiger. 
In  the  acini  of  the  glandula  submaxillaris  and  in  the 
other  acinous  glands  he  could  not  discern  them. 

E.  Klein'  asserts  that  he  has  observed  tliat  the  rods  or 
fibrils  of  Heidenhain,  when  looked  at  from  the  surface, 
are  connected  into  a  network,  so  that  they  are  more 
probably  septa  of  a  honey-combed  network  seen  in  pro- 
file. What  the  intimate  nature  of  these  formations  is 
neither  of  the  above-named  authors  attempts  to  explain. 
My  own  researches,  I  hope,  will  prove  theu"  nature, 
though  as  to  their  significance  I  have  only  suggestions 
to  make.  Since  the  reticular  stricture  of  all  protoplas- 
mic formations,  including,  therefore,  epithelium,  was 
demonstrated  by  C.  Heitzmann,"  the  question  has  been 
what  the  reticulum  present  in  the  protoplasm  is.  Un- 
questionably the  two  main  properties  of  living  matter 
are  motion  and  production  of  its  own  kind.  Both  these 
properties  are  attributes  of  the  reticulum  within  the 
protoplasm.  As  long  as  a  protoplasmic  body  is  alive 
and  endowed  with  the  property  of  amoeboid  motion  and 
locomotion,  the  reticulum  in  it  is  never  in  a  state  of  per- 
fect rest.  We  constantly  see  changes  in  the  configura- 
tion of  the  reticulum.  We  see  that  in  a  portion  of  the 
protoplasmic  body  the  reticulum  becomes  very  narrow, 
while  in  an  opposite  portion  it  is  simultaneously  wi- 
dened, especially  so  when  a  prolongation  of  the  body,  a 

'  Atlas  of  Histology,  London,  1880. 

-  "  Untersucliungen  liber  das  Protoplasma  :  "  Sitznngsbericlite  d  kaiserl. 
Akad.  d.  Wissenscli.  in  Wien.,  1873, 


10  beight's  disease. 

pseudopodmm,  is  pushed  out.  In  such  a  flat  offshoot, 
or  false  leg,  the  reticulum  may  be  stretched  to  such  a 
degree  that  the  projection  looks  homogeneous,  as  if  des- 
titute of  any  structure. 

The  writer  above  quoted  claims  that  the  narrowing  of 
the  reticulum  is  the  state  of  contraction  which  is  an  ac- 
tive property  belonging  to  it.  The  stretching,  on  the 
contrary,  represents  the  state  of  extension  which  is 
merely  passive,  due  to  the  pressure  of  the  liquid  pushed 
out  from  the  contracted  portion  into  that  at  compara- 
tive rest,  this  contracted  portion  being  immediately  after 
extended. 

The  foregoing  is  tenable  only  if  we  admit  the  presence 
of  an  investing  layer  around  the  protoplasmic  body 
which  prevents  the  liquid  filling  the  meshes  from  escap- 
ing outward.  The  flat  investing  layer  is  claimed  to  be 
identical  in  its  nature  with  the  mass  composing  the  re- 
ticulum proper.  It  is  maintained,  also,  that  the  reticu- 
lum at  any  time,  and  almost  instantaneously,  may  be 
transformed  into  a  flat  layer,  as  is  the  case  in  the  for- 
mation of  an  investing  layer  around  a  vacuole.  Vice 
versa,  the  flat  layer  almost  instantaneously  may  fall 
back  into  the  reticular  structure  at  the  moment  of  dis- 
appearance of  the  vacuole.  This  continuous  change  of 
shape  and  place  of  the  reticulum  is  a  positive  proof  of 
its  being  living  matter.  S.  Strieker,'  among  the  most 
recent  observers,  describes  the  reticular  structure  and 
its  changes  as  follows  : 

"The  interior  of  the  cell-bodies  undergoes  manifold 
visible  variations.  One  of  the  most  remarkable  instances 
is  furnished  in  the  saliva  corpuscles.  The  assumption 
that  a  so-called  molecular  motion  takes  place  in  the 
saliva  corpuscles  is  erroneous.  The  granules  seen  with 
insuflicient  amplifications  are  transverse  sections  of  tra- 


'  "  Mittheilung  iiber  Zellen  und  Grundsubstanzen  :  "     Med.  Jalirbiiclier, 
1880. 


EPITHELIA   OF   THE   TUBULES.  11 

beculse.  The  saliva  corpuscle  is  traversed  by  a  sharply 
marked  trabecular  structure,  w^hich,  so  long  as  the  cor- 
puscle is  fresh,  executes  lively  wavy  motions.  The 
vi^aving  gradually  ceases  on  addition  of  solutions  of  salts 
in  certain  concentration,  and  the  reticular  structure  dis- 
appears. The  waving  is  now  replaced  by  very  slowly 
formed  changes  in  the  interior  mass." 

A  second  proof  of  the  reticulum  being  the  living  mat- 
ter proper  rests  upon  the  fact  that,  both  in  normal  and 
in  morbid  processes,  the  new  formation  of  corpuscular 
elements  starts  from  the  points  of  intersection  in  the 
reticulum.  This  so-called  endogenous  new  formation 
of  living  matter  is  especially  plain  in  the  inflammatory 
process  invading  epithelial  formations.  Here,  it  is  im- 
portant to  note,  the  reticulum  at  first  becomes  coarse, 
next  it  coalesces  into  lumps,  which,  being  at  first  homo- 
geneous, in  turn  assume  a  reticular  structure  themselves, 
and  now  represent  so-called  inflammatory  or  pus  cor- 
puscles. These  corpuscles  at  first  remain  in  connection 
with  the  neighboring  reticulum  by  means  of  delicate 
filaments,  which  are  portion  and  part  of  the  reticulum. 
Later,  when  the  pus  corpuscles  which  have  originated 
in  the  interior  of  an  epithelium  become  extruded  from 
its  interior,  the  newly  formed  corpuscles  represent  pus 
corpuscles. 

In  conducting  my  researches,  I  have  studied  the  kid- 
neys of  the  rabbit,  pig,  dog,  and  man,  all  of  them  being 
preserved  and  hardened  in  a  solution  of  chromic  acid. 
I  have,  therefore,  no  observations  to  report  upon  the 
form-changes  of  the  epithelia,  but  have  studied  the 
changes  in  the  interior  structure  of  the  epithelia  in  the 
inflamed  human  kidney  as  they  appear  in  chronic 
croupous,  in  chronic  interstitial  nephritis,  in  waxy  de- 
generation of  the  kidney,  in  fatty  degeneration,  and 
in  chronic  interstitial  nephritis  with  acute  recurrence. 
These  investigations  enable  me  to  maintain  that  the  re- 


12  bright' S   DISEASE. 

ticular  stracture  of  the  epithelium  of  the  kidney  is 
really  a  formation  of  limng  matter. 

Upon  closely  examining  the  epifchelia  of  the  tubuli 
uriniferi  in  the  kidneys  of  the  above-named  animals, 
we  readilj''  perceive,  with  comparatively  low  powers  of 
the  microscope  (400  or  500  is  sufficient),  the  presence  of 
rod-like  formations  in  the  epithelia  of  the  tubuli  con- 
torti,  in  the  irregular  tubules,  in  the  ascending  branch 
of  the  looped  tubules,  and  in  the  intercalated  tubules, 
entirely  in  accordance  with  Heidenhain's  assertions,  al- 
though he  does  not  include  the  kidneys  of  the  pig. 

The  drawings  of  the  rodlets,  as  given  by  Heidenhain 
in  Max  Schultze's  "  Archiv,"  and  copied  by  Klein  and 
other  writers,  give  an  exaggerated  idea  of  the  real  ap- 
pearance of  the  rods.  Even  under  a  high  power  they 
are  never  so  large  as  in  the  drawings,  and  seldom  pre- 
sent the  straight,  regular,  and  symmetrical  appearance 
there  represented.  The  accompanying  drawing  (Fig.  3) 
more  nearly  represents  their  average  appearance  under 
a  power  of  1,200. 

I  have  found  them  in  the  healthy  kidney  as  follows  : 

In  man,  in  the  ascending  tubules,  power  1,200. 

In  the  rabbit,  power  500  to  600,  in  convoluted,  in 
ascending,  and  in  irregular  tubules.  Also  (never  before 
mentioned)  in  a  portion  of  the  descending  tubules. 

In  the  pig,  in  the  convoluted  and  irregular  tubules ; 
and  in  the  same  tubules,  and  narrow  tubules,  in  which 
the  rods  are  very  faintly  shown,  of  the  pup. 

The  pale,  flat  epithelia  of  the  looped  tubule  proper  do 
not,  as  a  rule,  exhibit  the  rods.  The  columnar  epithelia 
of  the  collecting  tubules,  on  the  contrary,  which  are 
distinctly  imbricated,  especially  in  the  kidney  of  the 
dog,  exhibit  the  rods  more  or  less  plainly.  The  colum- 
nar epithelium  of  the  rabbit  does,  however,  show  them. 
High  powers  (1,000  to  1,200)  of  the  microscope  corrob- 
orated the  views  of  Klein — namely,  that  the  rods  are 


RODLIKE   STRUCTURE   OF  THE   EPITHELIA. 


13 


connected  with  a  reticulum  by  means  of  delicate  fila- 
ments inosculating  both  with  the  wall  of  the  nucleus 
around  which  the  rods  are  located,  and  also  with  the 
delicate  reticulum  in  the  inner  portion  of  the  epithelia, 
next  to  the  caliber,  where  the  rods  are  usually  absent. 
It  is  striking  how  the  thickness  of  the  rods  differs  in 
the  different  epithelia  of  the  same  animal's  kidney. 


Fig.  4. — Straight  Tubule  from  the  Kidney  of  a  Eabbit.  (Longitudinal  section — 
magnified  1.20U  diameters.)— -iV^,  nucleated  columnar  epithelium,  showing  the  rods;  E,  endo- 
thelia  ;  /,  interstitial  connective  tissue,  producing  the  basement  layer. 


Sometimes  they  are  very  thin,  beaded  poles,  with  quite 
distinctly  marked  interstices  between  them.  In  this 
case  the  connecting  filaments,  running  almost  at  right 
angles  from  rod  to  rod,  are  easily  discernible.  At  other 
times  the  rods  are  rather  bulky  formations,  having  but 
extremely  narrow  interstices  between  them.  In  this  in- 
stance the  connecting  filaments,  as  a  matter  of  course, 
are  very  short,  and  not  easily  seen.  In  a  third  instance 
the  outermost  portion  of  the  epithelium  is  a  compact  or 


14  beight's  disease. 

homogeneous  mass,  in  wliich  no  rods  can  be  observed 
at  all. 

Another  striking  feature  is  the  great  variety  of  ap- 
pearances exhibited  by  the  cement-substance.  Some- 
times this  is  plainly  marked  at  regular  intervals  between 
the  epithelia.  Then  the  transverse  connecting  filaments, 
the  formerly  so-called  thorns,  are  plainly  visible.  At 
other  times  hardly  any  trace  of  cement-substance  is 
seen,  but  the  reticular  structure  is  present  in  a  nearly 
uniform  distribution  throughout  the  epithelial  layer. 
S.  Strieker  (Zoc.  cit)  was  the  first  who  observed  these 
same  varieties  in  the  appearance  of  the  cement-sub- 
stance in  the  epithelial  layer  of  the  cornea  ;  also,  that 
the  nucleus  varies  greatly  in  the  degree  of  distinctness 
in  which  it  comes  to  observation.  Where  the  rods  are 
slender,  the  nucleus,  as  a  rule,  is  well  defined ;  where, 
on  the  contrary,  they  are  bulky,  the  nucleus  is,  on  an 
average,  not  very  plainly  marked.  The  sharpest  defi- 
nition of  the  nucleus  is  furnished  by  the  flat  epithelia 
of  the  looped  tubules  in  which  the  rods,  as  before  men- 
tioned, are  absent. 

In  inflamed  kidneys  of  man  I  have  repeatedly  found 
the  rods  as  follows  : 

1.  In  chronic  interstitial  nephritis  : 

a.  In  the  convoluted  tubules. 
h.  In  the  straight  tubules. 

2.  In  acute  croupous  nephritis  : 

a.  In  ascending  tubules. 

3.  In  chronic  croupous  nephritis,  in  the  straight  tu- 
bules. 

4.  In  chronic  croupous  nephritis  w4th  waxy  degenera- 
tion, cross-sections  of  ascending  tubules  show  the  rods 
rather  enlarged.  Also  in  straight  tubules  in  the  pyra- 
mid of  the  same  kidney. 

5.  In  chronic  croupous  nephritis  with  acute  recur- 
rence, in  cross-sections  of  the  convoluted  tubules. 


KODLIKE   STRUCTURE    OF    THE    EPITHELIA.  15 

6.  In  fatty  degeneration  of  the  kidney,  in  cross- sec- 
tions of  the  convoluted  tubules.  The  rods  here  sliowed 
fat  globules.     The  connective  tissue  was  thickened. 

In  these  specimens  the  rods  of  the  epithelia  through- 
out the  tubules  are  clumsy  and  bulky,  the  whole  reticu- 
lum being  enlarged,  rendering  the  epithelium,  with  low 
powers  of  the  microscope,  coarsely  granular.  In  many 
instances  the  rods  are  not  discernible,  as,  in  their  place, 
a  coarsely  granular  mass  is  present,  pervading  the  whole 
epithelial  body ;  or  else  the  innermost  portion  of  the 
epithelium  looks  coarsely  granular,  the  outermost  por- 
tion, on  the  contrary,  being  homogeneous  and  shining. 
I  have  repeatedly  seen  in  acute  interstitial  nephritis  even 
the  looped  tubules,  which  in  this  situation  were  consid- 
erably increased  in  bulk,  provided  with  a  coarsely  gran- 
ular reticulum — nay,  even  with  an  indistinct  rod-like 
structure.  All  these  features  become  still  more  promi- 
nent by  staining  the  specimens  with  the  chloride  of  gold 
after  they  have  been  soaked  and  washed  for  several 
days  in  distilled  water.  This  reagent,  in  a  half-per- 
cent, solution,  brought  in  contact  with  the  specimens  for 
forty  minutes,  renders  sections  from  the  normal  kidney 
of  a  brown  violet  hue,  slightly  increasing  the  distinct- 
ness of  the  reticular  structure  of  tlie  epithelia.  In  the 
inflamed  kidneys  of  man,  the  ejDithelia  of  a  great  many 
of  the  ascending,  irregular,  and  convoluted  tubules,  upon 
being  stained  with  the  chloride  of  gold,  as  above  de- 
scribed, became  dark  violet.  AVith  higher  powers  of 
the  microscope  we  can  ascertain  that  it  is  the  coarse  re- 
ticulum, the  bulky  rods,  and  the  homogeneous  masses 
sprung  from  coalescence,  as  it  were,  of  the  rods,  which 
exhibit  the  deepest  gold  stain. 

As  it  is  the  tubuli  uriniferi  which  have  the  rod-like 
structure,  which  in  Heidenhain's  experiments  with  in- 
digo sulphate  are  the  only  ones  which  are  colored  by 
it,  so  in  the  infiamed  kidney  it  is  only  these  tubules  that 


16 


bright' S   DISEASE. 


become  colored  by  tlie  gold.  It  seems  reasonable  to 
suppose,  from  the  effect  of  these  reagents,  that  the 
epithelia  with  rods,  perhaps  by  virtue  of  their  having 
more  living  matter  and  a  more  bulky  reticulum,  are  of 
most  importance  in  secreting  or  forming  the  extractive 
matter  of  the  urine. 

Numerous  attempts  to  produce  the  stain  with  "the  gold 
in  the  healthy  kidney  of  the  dog,  pup,  rabbit,  and  pig 


Fig.  5. — CoNvoLnTED  Tubule  from  a  Human  Kidney  affected  with  Acute  Catab- 
KHAL  (Interstitial)  Nephritis.  (Oblique  section — magnified  1,200  diameters.) — P,  inflam- 
matory corpuscle,  sprung  from  the  division  of  an  epithelium  ;  D,  cluster  of  inflammatory 
corpuscles,  sprung  in  the  same  manner  ;  B,  rods  of  cuboidal  epithelia,  still  recognizable ;  E, 
endothelia,  increased  in  size  and  number. 


were  ineffectual  in  rendering  the  rods  plainer  than  in  the 
unstained  condition. 

In  the  inflamed  kidneys,  in  which  the  violet  coloration 
was  produced,  no  doubt  the  reticulum  of  the  epithelia, 
owing  to  the  inflammatory  process,  was  considerably 
increased  in  bulk.  The  most  marked  violet  stain  was 
exhibited  by  a  number  of  the  convoluted  tubules  and  by 
irregular  and  ascending  tubules.     We  know  that  living 


RODLIKE    STRUCTURE   OF    THE    EPITHELIA.  17 

matter  is  considerably  increased  in  amount  in  the  in- 
flammatory process,  and  are  justified,  consequently,  in 
maintaining  that  the  reticulum  and  rod-like  formations 
within  the  epithelium,  being  part  of  the  reticulum,  are 
formations  of  living  matter. 

As  to  the  significance  of  the  rods,  it  may  be  inferred 
from  the  statements  I  have  made  that  they  are  in  close 
relation  with  the  process  of  secretion.  Obviously,  the 
stream  of  liquid  running  from  the  neighboring  blood- 
vessels through  the  epithelia  toward  the  liquids  con- 
tained in  the  caliber,  and  vice  versa,  will  be  facilitated 
by  an  elongated  arrangement  of  the  reticulum — i.e.,  the 
rods.  In  a  state  of  comparative  rest  the  rods  lie  close 
to  each  other — nay,  are  coalesced  into  homogeneous 
masses.  In  this  condition  the  cement-substance  between 
the  epithelia  is  best  marked.  In  full  activity  of  the 
epithelium,  on  the  contrary,  the  rods  will  be  very  dis- 
tinct, will  stand  further  apart,  and  the  cement-sub- 
stance between  the  epithelia  will  in  consequence  become 
indistinct. 

2 


CHAPTEE  III. 

THE  ENDOTHELIA  OF  THE  URINARY  TUBULES. 

While  investigating  the  pecnliarities  in  the  structure 
of  epithelia  of  tubuli  nriniferi  in  their  normal  condi- 
tion, I  often  observed  the  presence  of  flat,  spindle-shaped 
bodies  between  the  basis  of  the  epithelia  and  the  adja- 
cent so-called  structureless  membrane  of  the  tubule. 
These  spindle-shaped  bodies  doubtless  correspond  to 
those  flat,  nucleated  formations  which  cover  the  inner 
surface  of  the  structureless  layer  in  nearly  all  epithelial 
— i.e.,  glandular — foraiations.  By  most  observers  they 
are  regarded  as  endothelia  belonging  to  the  connective 
tissue  subjacent  to  the  epithelial  layers.  Y.  Czerny  was 
the  first  one  to  bring  them  to  view  in  other  tissues, 
which  he  did  by  staining  the  specimens  with  the  nitrate 
of  silver  ;  and  C.  Ludwig,'  also  by  the  silver  stain,  first 
indicated  their  presence  in  the  urinary  tubules.  He 
does  not  fully  describe  them,  but  alludes  to  them  as 
follows.  Speaking  of  the  basement  membrane  of  the 
tubuli  uriniferi,  he  says:  "In  general  the  basement 
membrane  appears  to  be  homogeneous,  and  cannot  be 
further  divided ;  but  occasionally  a  nucleus  can  be 
brought  into  view  in  the  substance  by  carmine  ;  and  in 
some  instances,  and  for  short  distances,  the  same  ap- 
pearances occur  in  the  tortuous  canals,  when  treated 
with  nitrate  of  silver,  as  are  presented  by  the  blood  and 
lymph  capillaries  under  the  same  condition."  "The 
basement  membrane  is  as  clear  as  glass,  elastic."    "  The 

'  Hand-book  of  Histology,  by  S.  Strieker.    London,  1874. 


ENDOTHELIA  OF  THE  TUBULES.  19 

shape  of  the  nucleus  is  usually  the  same  in  all  instances, 
being  spherical,  sharply  defined,  and  with  numerous 
granules  scattered  through  its  substance." 

Such  an  endothelial  layer,  present  in  all  varieties  of 
the  urinary  tubules,  is  best  visible  in  the  front  view  of 
the  structureless  membrane,  where  the  epithelium  is 
stripped  off.  Here  the  endothelia  are  comparatively 
large,  irregularly  polyhedral  bodies,  with  distinct  cen- 
tral nuclei.  The  nucleus  has  a  plainly  marked  shell, 
containing  in  its  interior  a  few  small  nucleoli,  the  nuclei 
being  mostly  of  oblong  shape.  In  the  body  of  the  en- 
dothelium a  delicate  reticulum  is  seen  with  very  minute 
nodulations.  Each  body  is  separated  from  all  its  neigh- 
bors by  a  delicate  light  rim  of  cement-substance,  which 
is  traversed  at  right  angles  by  extremely  minute  fila- 
ments or  thorns.  In  side  view,  obviously,  these  bodies 
will  exhibit  a  spindle-shape,  the  broadest  portion  of  the 
spindle  corresponding  to  the  central  nucleus. 

If  the  views  of  recent  observers  are  correct — namely, 
that  the  structureless  layer,  synonymous  with  the  hya- 
line or  basement  layer,  is  an  aggregation  of  endothelia 
infiltrated  with  elastic  substance — this  view  may  also  be 
applied  to  the  structureless  membrane  of  the  urinary 
tubules.  In  normal  kidneys  I  failed  to  discover  nu- 
clei in  the  structureless  layer  proper,  which  would 
indicate  their  construction  of  former  endothelia.  In 
inflamed  kidneys,  on  the  contrary,  no  doubt  was  left 
as  to  the  fact  that  the  structureless  layer  is  composed 
by  a  number  of  closely  attached,  in  part  nucleated,  en- 
dothelia. 

I  have  found  the  endothelia  repeatedly  in  the  inflamed 
kidney  in  chronic  croupous  and  in  chronic  interstitial 
nephritis,  in  acute  interstitial  and  in  acute  croupous 
nephritis,  and  in  fatty  and  waxy  degeneration  of  the 
kidney.  I  have  found  them  most  frequently  in  the 
ascending,  descending,  and  convoluted  tubules.     I  am 


20 


bright' S   DISEASE. 


not  aware  tliat  any  observer  has  heretofore  recognized 
their  existence  as  having  a  pathological  significance. 

In  the  inflamed  kidney  the  endothelial  layer  beneath 
the  epithelial  is  always  more  marked  than  in  the  nor- 
mal kidney.  In  chronic  catarrhal  (interstitial  or  des- 
quamative) nephritis,  all  the  tubules  that  have  lost 
their  epithelial  investment  invariably  show  an  invest- 
ment of  endothelia. 


Fig.  6. — Convoluted  TnBirLE  from  a  Human  Kidney  affected  with  Chronic  Ca- 
TABEHAi  (Desquamative)  Nephkitis.  (Oblique  section— magnified  1,200  diameters.) — C, 
caliber,  widened  by  loss  of  the  epithelia  ;  E^  endothelia,  increased  in  size  and  number ;  F,  in- 
terstitial fibrous  connective  tissue,  with  augmented  plastids. 


This,  in  the  transverse  section  of  the  tubule,  is  char- 
acterized by  the  presence  of  flat,  irregularly  spindle- 
shaped  bodies,  which  are  always  more  coarsely  granular 
than  in  the  phj'-siological  condition.  Their  nuclei  are 
also  more  coarsely  granular,  sometimes  homogeneous. 
The  flat  shape,  the  large  size  in  the  frontal  diameter, 
and  the  construction  of  the  nuclei  serve  for  an  accurate 
contradistinction  to  epithelia.    I  have  failed  in  obtain- 


EISTDOTHELIA    OF    THE   TUBULES.  21 

ing  specimens  indicative  of  a  new  formation  of  epithelia 
after  the  loss  of  tlie  original  epithelial  investment. 

It  may  be  admissible  to  assume  that  the  enlarged  en- 
dothelial layer  serves  (at  least  to  some  extent)  as  a 
substitute  for  the  lost  epithelia.  In  tubules  v^^hose  epi- 
thelia, as  in  chronic  catarrhal  nephritis,  are  transformed 
into  inflammatory  or  medullary  corpuscles,  the  new 
formation  also  starts  from  the  endothelia.  The  final 
result  in  this  instance  is  known  to  be  the  destruction  of 
the  tubule  and  its  replacement  by  newly  formed  con- 
nective tissue — a  condition  which  is  known  by  patholo- 
gists as  cirrhosis  of  the  kidney. 

[Since  writing  the  rough  outlines  of  this  article,  I 
have  recognized  for  the  first  time  well-marked  endo- 
thelia in  the  urine  in  a  case  of  advanced  chronic  croup- 
ous nephritis  with  fatty  degeneration.  I  found  a  clus- 
ter of  three  or  four  of  these  surrounded  by  free  fat 
granules.] 

Still  more  plainly  marked  are  the  endothelia  in 
croupous  (parenchymatous)  nephritis.  In  fact,  the  ap- 
pearances seen  in  urinary  tubules  where  casts  have  just 
formed  could  not  be  explained  unless  by  the  presence 
of  endothelia. 

The  results  of  my  researches  may  be  summed  up  in 
the  following  statements  : 

1.  The  rods  discovered  by  Heidenhain  in  some  varie- 
ties of  the  tubuli  uriniferi  are  part  and  parcel  of  a  retic- 
ulum present  within  every  epithelium. 

2.  The  reticulum,  including  its  elongated  rodlike  for- 
mations, is  the  living  matter  proper. 

3.  The  relation  of  the  rods  to  the  rest  of  the  reticulum 
of  an  epithelial  body  varies  greatly,  the  variation  prob- 
ably being  due  to  different  stages  or  degrees  of  secretion. 

4.  The  reticulum,  including  the  rodlike  formations, 
in  the  infiammatory  process,  both  in  catarrhal  and 
croupous  nephritis,  gives  rise   to   a   new  formation  of 


22  BRIGHT  S   DISEASE. 

living  matter,   which  results  in  the  new  formation  of 
medullary  corpuscles  or  pus  corpuscles. 

5.  The  structureless  membrane  is  lined  by  flat  endo- 
thelia  lying  between  it  and  the  basis  of  the  epithelia  of 
the  urinary  tubules. 

6.  In  nephritis  the  endothelia  become  considerably 
enlarged,  and  in  catarrhal,  as  well  as  in  croupous  ne- 
phritis, they  line  the  urinary  tubules  after  the  epithelia 
have  been  shed  or  lost ;  they  surround  the  cast  in 
croupous  nephritis  after  the  epithelia  have  perished  in 
the  formation  of  the  cast. 


CHAPTER  ly. 

THE   CONNECTIVE   TISSUE   OF   THE   KIDNEY. 

The  importance  of  this  tissue  will  be  readily  understood 
when  we  consider  that  to  its  lesions  is  due  one  of  the 
most  common  forms  of  Bright' s  disease,  namely,  inter- 
stitial nephritis. 

According  to  G.  Johnson  ("  Lectures  on  Bright' s  Dis- 
ease") this  connective  tissue  does  not  exist  in  the  laby- 
rinth, but  I  have  repeatedly  recognized  it  in  healthy 
kidneys  of  man,  of  the  rabbit,'  dog,  and  pig.  No  fibril- 
lated  connective  tissue  exists  between  the  tubuli  con- 
torti.  It  is  found,  however,  in  the  tissue  immediately 
surrounding  the  Malpighian  corpuscles,  and  especially 
those  lying  close  to  the  medulla.  These  are  often  en- 
closed by  fibrous  connective  tissue. 

Elsewhere,  only  isolated  small  fusiform  cells  lie  be- 
tween the  blood  capillaries  and  the  urinary  tubules  of 
the  labyrinth.  They  do  not,  however,  in  any  way  bind 
the  convolutions  of  the  tubuli  uriniferi  either  to  one 
another  or  to  the  blood-vessels.  The  spaces  between 
the  tubules  of  the  medulla  in  the  immediate  neighbor- 
hood of  the  papilla  are  filled  with  a  distinctive  fibrillated 
connective  tissue  surrounding  the  urinary  tubules  in  a 
concentric  manner.  The  nearer  we  approach  the  limit- 
ing layer  the  more  delicate  becomes  the  fibrillation  and 
the  more  abundant  the  cellular  elements.  (Ludwig,  in 
Strieker's  ' '  Histology. ' ' ) 

The  capillaries  forming  the  glomerulus  are  covered  by 
delicate  connective  tissue.     This  delicate  layer  also  lines 


24  bright' S   DISEASE. 

the  capsule,  both  layers  being  covered  with  epithelia ; 
according  to  Heitzmann  that  upon  the  glomerulus  be- 
ing cuboid  in  the  fcetus  and  flat  in  the  adult,  while  that 
upon  the  parietal  portion  is  flat.  In  scarlatina,  in  the 
case  of  patients  who  succumbed  rapidly  from  anuria, 
Mr.  Klebs  states  that  he  found  the  only  lesion  in  the 
kidney  to  be  an  excessive  multiplication  of  the  cells  (or 
epithelia)  of  the  connective  tissue  of  the  glomerulus, 
naturally  producing  compression  of  its  blood-vessels. 
There  is  no  doubt,  however,  that  inflammation  of  the 
glomerulus  could  not  exist  without  inflammations  of 
other  portions  of  this  organ.  The  convoluted  tissue  of 
the  glomerulus  is  often  thickened,  but  not  indepen- 
dently of  other  inflammation. 


CHAPTER  V. 

THE  CIRCULATION  OF  THE  KIDNEY, 

The  greater  part  of  the  renal  arteries  run  into  the  cor- 
tex, forming  arterise  interlobulares.  A  small  portion 
of  these  penetrate  to  the  fibrous  capsule,  and  each  arte- 
ria  interlobular  is  sends  to  a  Malpighian  body  a  small 
trunklet  called  a  xias  afferens  ;  a  few  of  these  ^asa  affer- 
entia  give  off  fine  branches  which  break  up  into  capilla- 
ries through  which  the  blood  passes  into  the  capillary 
plexuses  surrounding  the  urinary  tubules. 

The  'Gas  efferens,  which  contains  arterial  blood,  after 
leaving  the  capsule  of  Bowman  runs  immediately  to  the 
medullary  ray,  subdividing,  as  it  extends,  into  a  capil- 
lary network  and  running  in  part  to  the  cortical  sub- 
stance. From  the  capillaries  of  the  cortical  substance 
thus  formed,  descend  straight  branches,  supplying  the 
medullary  rays.     These  are  the  true  vasa  recta. 

The  labyrinth  derives  its  supply  of  blood  from  the 
capillaries  running  upward  from  the  efferent  vessel. 

The  capillaries,  composing  a  plexus  surrounding  a 
medullary  ray,  are  never  closely  adherent  to  the  urinary 
tubules,  lacuniform  spaces,  frequently  filled  with  fluid, 
intervening  between  the  walls  of  the  blood  and  the  uri- 
nary vessels. 

Both  these  varieties  run  immediately  toward  the  fis- 
sure-like space  in  the  marginal  layer  of  the  medulla, 
between  the  fasciculi  of  the  tubuli  uriniferi.  They 
break  up  into  capillaries  that  form  looped  plexuses 
about  the  tubules.     The  circulation  of  the  medullary 


26 


bright' S   DISEASE. 


portion  is  therefore  derived  from  the  capillaries  di- 
rectly arising  from  the  vasa  efferentia  and  from  the  vasa 
recta  descending  from  the  cortical  plexus.  ' '  The  i:)eins 
arise  from  the  capillaries  of  the  cortical  substance,  es- 


FiG.  7.  (From  Heitzmann.) — Boundaet  Line  between  the  Cortical  and  Pyramidal 
Substance  of  the  Kidney  of  a  Dog.  Blood-vessels  Injected. — 4,  branch  of  renal  ar- 
tery; Co,  prolongiition  of  the  cortical  substance;  T,  tuft;  <S',  bundle  of  straight  tubules;  O, 
origin  of  the  vasa  recta  from  the  capillaries  of  the  cortical  substance  ;  B,  bundle  of  vasa  recta, 
magnified  100  diameters. 

pecially  those  of  the  labyrinth,  and  their  confluence  is 
often  marked  on  the  surface  of  the  kidney  in  the  form 
of  stars.  As  the  medullary  rays  are  lost  near  the  sur- 
face of  the  kidney  and  the  outermost  portion  of  the  cor- 
tex has  no  tufts,  obviously  the  veins  arise  from  the 


CIECULATlOlSr    OF   THE   KIDNEY.  27 

capillary  system  surrounding  tlie  convoluted  tubules. 
The  veins  accompany  the  arteries,  and  empty  into  the 
venous  plexus  at  the  boundary  zone  between  the  cortex 
and  the  pyramis.  The  latter  furnishes  veins  derived 
both  from  the  capillaries  of  the  collecting  tubules  and 
from  the  vasa  recta,  the  ascending  loops  of  which  empty 
directly  into  the  inter-zonal  venous  plexus."  (Heitzmann, 
loc.  cit,  p.  738.) 


CHAPTER  yi. 

NERVES  OF  THE  KIDNEY, 

Have  not  by  histologists  received  the  attention  tliey 
merit.  Among  the  most  valuable  investigations  are 
those  made  by  Dr.  Holbrook.' 

"He  found  a  large  number  of  nerves  accompanying 
the  arteries  and  producing  a  reticulum  around  the  ca- 
pillaries in  accordance  with  the  statements  of  L.  Beale. 
Every  tubule  is  accompanied  by  a  reticulum  of  non- 
meduUated  nerve-fibres  from  which  prolongations  pass 
through  the  basement  membrane  and  produce  a  very 
narrow  plexus  close  above  this  membrane.  From  the 
inter-tubular  plexus  delicate  branches  arise,  running 
along  the  cement-substance  of  the  epithelia  and  in  union 
with  the  slender,  transverse  filaments  traversing  the 
cement-substance  and  inter-connecting  the  epithelia. 
By  Holbrook'  s  specimens  it  is  plainly  shown  that  every 
epithelium  is  in  connection  with  a  nerve-fibre,  though 
this  connection  is  indirect  through  the  inter-epithelial 
filaments  of  living  matter  (the  so-called  thorns).  It 
could  not  be  demonstrated  that  the  nerve-fibrillse  pene- 
trate the  interior  of  the  epithelia." 

'  Heitzmauu  :  Microscopical  Morphology,  p.  748. 


CHAPTER   yil. 

NATURE   AND  SOURCES  OF   THE   URINARY   SECRETION   AND 
EXTRACTIVES. 

In  the  language  of  Hofmann  and  Ultzmann,  "  The  urine 
is  the  secretion  of  the  kidneys,  and  under  normal  con- 
ditions is  essentially  a  solution  of  such  ingredients  as 
belong  to  retrograde  tissue-metamorphosis.  It  is  a  so- 
lution of  urea  and  chloride  of  sodium,  to  which  are 
added  in  less  proportion  other  organic  and  inorganic 
constituents  of  the  blood,  as  well  as  certain  foreign 
matters  introduced  into  the  organism,  which  are  excreted 
through  the  kidneys  unaltered,  or  having  previously 
undergone  chemical  transformation. 

"  In  a  normal  condition  the  urine  contains  in  part  or- 
ganic constituents,  as  urea,  uric  acid,  creatinine,  liippu- 
ric  acid,  xanthine,  lactic  acid,  coloring  matters,  indican, 
grape  sugar  (Briicke),  etc.;  partly  inorganic,  chloride 
of  sodium,  phosphates  of  sodium,  magnesium,  and  cal- 
cium, sulphates  of  the  alkalies,  iron,  and  ammonium 
salts  as  constituents  of  the  coloring  matters  ;  and  gases 
— carbonic  acid,  nitrogen,  and  oxygen.  In  pathological 
urine,  grape  sugar,  inoside,  biliary  matters,  fat,  sulphu- 
retted hydrogen,  coloring  matters  of  the  blood,  uroery- 
thrine  (Heller),  leucine,  and  tyrosine,  oxalate  and  carbo- 
nate of  calcium,  carbonate  of  ammonium,  cystine,  pus, 
blood,  epithelium,  spermatozoa,  fungi,  and  infusoria."  ' 

That  the  glomerulus  Malpighianus  is  the  principal 

'  Hofmann  and  Ultzmann  :  Analysis  of  the  Urine,  pp.  31,  32.  New  Yorli^ 
1879. 


30  bright' S   DISEASE. 

source  of  the  aqueous  secretion,  is  now  generally  con- 
ceded. The  delicate  thin  membrane  of  which  its  ves- 
sels are  composed  permits  of  an  easy  separation  of  the 
watery  portion  of  the  blood,  and  this  facility  is  made 
greater  by  the  volume  of  its  vessels,  which  are  large  in 
proportion  to  the  means  of  exit  of  their  blood,  which 
can  take  place  only  through  the  narrow  orifices  of  the 
i^asa  efferentia.  Hence  arises  a  temporary  retardation 
of  circulation  in  the  vessels  of  the  glomerulus,  which 
would  become  permanent  except  that  the  congestion  is 
kept  down  by  the  escape  of  the  water,  which  flows  into 
the  commencement  of  the  uriniferous  tubule.  JN'ot  only 
is  water  secreted,  but  under  certain  circumstances  albu- 
men. The  transudation  is  increased  by  any  obstacle  to 
the  flow  through  the  vessels,  or  by  greatly  increased 
pressure. 

As  is  well  known,  Ludwig  regards  the  functions  of 
the  glomerulus  to  consist  simply  in  the  mechanical  fil- 
tration of  the  water  of  the  blood,  holding  all  the  urinary 
constituents  in  the  blood  pre-formed,  in  solution.  Ac- 
cording to  Bowman's  theory,  the  Malpighian  tufts 
secrete  essentially  only  the  water  of  the  urine  with  a 
small  part  of  the  crystallized  salts,  while  the  specific 
elements  of  the  urine  are  excreted  by  the  epitlielia  of 
the  convoluted  tubules. 

Recent  experiments,  however,  made  by  Overbeck, 
Nussbaum,  and  Heidenhain,  demonstrate  the  following 
facts  : 

1.  That  the  separation  of  the  water  from  the  blood, 
which  takes  place  principally  in  Bowman's  capsule, 
"  is  not  wholly  a  simple  physical  phenomenon  compar- 
able to  that  which  in  our  laboratories  is  effected  through 
inert  membranes,"  '  but  that  it  is  mostly  performed  by 
the  epithelia  of  the  glomerulus. 

'  Charcot :  Sur  rAlbuminurie. 


SOURCES    OF   THE   UEINARY    SECRETIOIS'.  31 

2.  That  tlie  albumin  and  sugar  are  separated  from 
tlie  blood  by  the  glomerulus. 

3.  That  while  some  of  the  urine  extractives,  as  urea 
and  uric  acid,  pre-exist  in  the  blood  and  are  separated 
from  it  by  the  epithelia  of  the  convoluted  and  straight 
tubules,  the  epithelia  of  the  tube  system  do  not  act  in 
all  cases  as  merely  separators  of  previously  existing 
substances,  but,  as  has  been  shown  by  the  experiments 
of  Schmiedberg  and  Koch,  are  really  formative.  Hip- 
puric  acid  exists  only  in  feeble  proportion  in  the  urine 
of  man ;  it  is  found  mostly  in  the  urine  of  herbivorse, 
but  in  these  it  does  not  pre-exist  in  the  blood.  (Hip- 
puric  acid  may  be  considered  as  a  combination  of  ben- 
zoic acid  and  glycocolle — sugar  of  gelatine. ) 

Now  according  to  the  experiments  last  referred  to,  if 
into  the  blood  of  a  dog  benzoic  acid  and  glycocolle  are 
injected  and  the  ureter  tied,  a  certain  quantity  of  hip- 
puric  acid  accumulates  in  the  blood.  It  is  evident 
that  this  hippuric  acid  must  have  been  formed  in  the 
kidney  by  synthesis,  from  the  fact  that  if  the  vessels  of 
the  kidney  and  not  the  ureter  are  tied,  the  hippuric 
acid  is  not  found  in  the  blood.  The  next  experiment  is 
yet  more  conclusive.  If  one  kidney  of  a  live  dog  is  ex- 
tirpated, and  blood  containing  benzoic  acid  and  glyco- 
colle is  injected  through  the  principal  artery  of  the 
kidney  hippuric  acid  is  formed  in  the  blood.  This 
synthesis  may  be  made  at  a  cool  temperature,  and  in  a 
kidney  extirpated  as  long  as  forty-eight  hours. 

The  epithelia  of  the  kidney,  therefore,  perform  the 
functions  of  separation  as  regards  urea  and  uric  acid, 
and  of  secretion  or  formation  as  regards  hippuric  acid. 
This  being  shown,  we  may  assume  that  other  elements 
of  the  urine  are  secreted  by  the  epithelia  of  the  tube 
system.  In  fact,  as  urea  and  uric  acid  exist  pre-formed 
in  the  blood  in  minute  quantities  only,  we  may  conclude, 
as  they  are  voided  in  the  urine  in  so  much  larger  quan- 


32  bright' S   DISEASE. 

tity,  that  the  functions  of  the  epithelia  as  regards  urin- 
ary salts  are  formative  or  secretory. 

As  regards  the  untenableness  of  Lud wig's  theory  of 
the  formation  or  secretion  of  all  the  urinary  extractives 
in  Bowman's  capsule — a  theory,  I  may  add,  which  was 
also  held  by  the  late  Dr.  Charles  Isaacs,  U.  S.  Army, 
who,  I  believe,  first  demonstrated  that  the  Malpighian 
tuft  was  covered  by  epithelia,  and  by  the  late  John  W. 
Draper — the  remarks  of  Beale  are  of  interest. 

"  If  the  urine  were  secreted  in  its  fully  formed  state 
by  the  agency  of  the  vessels  of  the  Malpighian  body  and 
the  epithelium  covering  it,  it  is  difficult  to  find  an  ex- 
planation of  the  fact  that  in  every  mammalian  animal 
such  fully  formed  urine  is  made  to  pass  down  a  very 
long  and  tortuous  tube,  instead  of  a  short  straight  one. 
And  it  might  be  argued  that,  admitting  a  thin  layer  of 
epithelia  to  exist  upon  the  capillaries  of  the  Malpighian 
bodies,  it  seems  very  improbable  that  these  alone  should 
be  concerned  in  the  secretion  of  the  urine,  while  the 
large  cells  in  such  great  number  lining  the  uriniferous 
tube  are  destined  to  perform  no  important  ofiice  ;  and 
the  difficulty  is  much  increased  when  we  consider  that 
the  convolutions  of  the  tube  permit  so  large  a  number 
of  these  cells  to  be  packed  in  very  small  space. 

"  It  seems  extraordinary  that  any  one,  after  carefully 
comparing  the  Malpighian  bodies  of  man  and  animals, 
which  secrete  much  fluid  urine,  with  those  of  birds  and 
reptiles,  which  have  urine  of  a  pasty  and  nearly  solid 
consistence,  should  come  to  the  conclusion  that  these 
organs  are  not  destined  for  the  transudation  of  water 
from  the  blood. 

"The  idea  of  the  capillaries  of  the  straight  portion  of 
the  uriniferous  tubes  being  principally  concerned  in  this 
process  is  still  more  astonishing,  because  one  cannot 
understand  how  those  who  maintain  such  a  doctrine  fail 
to  see  that  the  arguments  they  advance  in  favor  of  their 


SOUECES   OF  THE   UEINAEY   SECEETIOI^.  33 

own  view  apply  with  tenfold  force  to  the  capillaries  of 
the  Malpighian  bodies.  If  water  passes  from  the  capil- 
laries around  the  straight  portion  of  the  tube,  it  must 
traverse  the  capillary  wall,  connective  material,  and 
lastly  the  thick  wall  of  this  portion  of  the  uriniferous 
tube."  ' 

Urea  has  been  found  in  the  blood  under  ordinary 
circumstances,  and  in  gout.  Dr.  Garrod  has  been  able 
to  detect,  by  very  delicate  tests,  traces  of  uric  acid  in 
the  blood  in  health  ;  while  in  gout,  uric  acid,  free  or  in 
combinations  with  soda,  can  always  be  found.  These, 
however,  are  mainly  formed  in  the  kidney,  inasmuch  as 
when  these  organs  are  removed  no  traces  of  these  salts 
can  be  found  in  any  of  the  tissues.  The  various  ex- 
tractives are  undoubtedly  formed  principally  in  the 
kidney,  as  the  bile  is  formed  in  the  liver.  Some  experi- 
ments notably  demonstrate  this. 

If  the  renal  vein  be  tied,  more  urea  is  found  in  the 
blood  than  if  the  kidneys  be  extirpated.  When  these 
organs  are  removed,  no  urea,  or  only  a  trace,  is  found 
in  the  blood  ;  but  if  the  ureters  be  tied,  the  accumula- 
tion is  very  considerable. 

These  conclusions  will  be  sustained  en  route  by  other 
proofs ;  but  enough  has  been  said  to  prove  that  the 
function  of  the  glomerulus  is  to  separate  the  aqueous 
portions  of  the  blood,  while  the  specific  products  are 
formed  or  secreted  by  the  tubular  apparatus. 

There  seem  to  be,  however,  but  few  supporters  of 
the  doctrine  that  uric  acid  and  urea  are  formed  in  the 
kidneys. 

It  now  remains  to  determine  by  what  parts  of  the 
kidney  these  secretions  are  eliminated  or  formed,  and 
how. 

Experiments  show  quite  satisfactorily  that  the  selec- 

'  Beale  :  Kidney  Diseases,  p.  34. 


34  beight's  disease. 

tion  of  these  products  takes  place  in  the  convoluted 
tubules  and  in  the  loop  system.  The  collecting  tubules 
may  be  excluded  as  belonging  only  to  the  excretory 
apparatus. 

Charcot  considers  that  this  elimination  takes  place  in 
those  portions  of  the  tubuli  uriniferi  that  are  lined  by 
a  cloudy  or  rodlike  epithelium,  namely,  the  tubuli  con- 
torti  and  the  ascending  branch  of  Henle's  loop.  The 
function  of  these  epithelia  is  undoubtedly  the  separation 
from  the  blood,  which  is  contained  in  the  capillary  plex- 
uses surrounding  these  tubes,  formed  by  the  branches 
of  the  laasa  efferentia,  of  a  considerable  quantity  of 
the  debris  of  the  blood  corpuscles  in  the  form  of  extrac- 
tive matter. 

If  it  as  yet  be  not  conclusively  proven  that  the  epi- 
thelia have  the  power  of  altering  some  of  the  substances 
they  separate  from  the  blood  and  converting  them  into 
urea,  uric  acid,  and  the  peculiar  urine  extractives  of 
which  so  large  an  amount  is  excreted,  the  functions  of 
the  epithelia  of  the  loop  system  in  the  separation  or  se- 
cretion of  the  urinary  salts  is  shown  conclusively  by 
Heidenhain's  experiments.' 

If  the  water  and  the  specific  principles  were  both  se- 
creted by  the  glomerulus,  the  suppression  of  the  former 
would  involve  the  suppression  of  the  latter.  Such,  how- 
ever, is  not  the  case.  The  watery  secretion  may  be  in- 
terrupted by  diminishing  arterial  pressure  in  the  kid- 
ney, by  copious  blood-letting,  or  by  division  of  the 
spinal  cord  below  the  medula  oblongata.  If,  in  an  ani- 
mal whose  spinal  cord  has  been  divided,  an  injection  of 
a  solution  of  sulphate  of  indigo  sodique  be  made,  not 
the  most  minute  quantity  of  urine  reaches  the  bladder, 
but  the  coloring  matter  passes  into  the  kidney.  It  is 
secreted  but  not  excreted.     In  such  a  case  it  is  not  dif- 

'  Given  in  detail  in  Charcot  on  Bright's  Disease,  Millard's  translation. 


SOURCES   OF   THE   URUSTARY   SECRETIOlSr.  35 

fused,  as  in  the  normal  condition,  throngliout  the  kid- 
ney ;  it  occupies  only  the  cortical  substance. 

The  microscope  enables  us  to  determine,  thanks  to  the 
blue  tint,  what  parts  of  the  uriniferous  tubules,  and  in 
these  tubules  what  elements,  are  concerned  in  this  elimi- 
nation. "The  parts  which  are  colored,  then,  are :  First, 
the  convoluted  tubules  ;  second,  the  ascending  branches 
of  Henle's  loop.  The  capsules  of  Bowman,  on  the  con- 
trary, as  well  as  the  descending  tubes  of  the  loop,  do 
not  present  the  slightest  trace  of  blue."  (See  Charcot, 
American  edition,  p.  21.)  These  portions  are  the  very 
ones  lined  by  a  rodlike  epithelium.' 

"  If  the  animal  be  killed  ten  minutes  after  the  injec- 
tion, we  perceive  that  the  coloring  matter  impregnates 
solely  the  epithelia.  If  the  animal  be  killed,  on  the 
contrary,  an  hour  or  later  after  the  injection,  we  find  the 
epithelial  ceils  colorless,  and  the  blue  matter  to  have 
passed  into  the  lumen  of  the  canals,  where,  owing  to  the 
absence  of  water,  it  is  found  in  a  highly  concentrated 
state — that  is,  in  the  form  of  a  crystalline  deposit." 
(Charcot,  p.  21.) 

It  is  evident  enough  that  in  this  experiment  this  sub- 
stance is  selected  from  the  blood  contained  in  the  capil- 
lary plexus  surrounding  the  tubules  and  derived  from 
the  vasa  efferentia. 

"There  is  every  reason  for  believing  that  phenomena 
essentially  the  same  occur  when  the  secretion  of  the 
water  is  allowed  to  continue  ;  only,  under  the  influence 
of  this  secretion,  the  coloring  matter  is  carried  away  far 
from  the  primitive  seat  of  elimination — that  is,  it  is  dif- 
fused into  the  descending  or  slender  branches,  into  the 
collecting  tubes,  and  finally  into  the  urine.  It  is  this 
that  happens  when,  at  a  certain  moment  following  close 
upon  the  injection,  all  the  parts  of  the  kidney,  with  the 

'  I  have  shown  since  Heidenhain's  investigations  that  the  descending  tu- 
bules in  the  rabbit  show  the  rods.     {Vids  Chapter  II.) 


36  bright' S   DISEASE. 

exception  of  the  glomeruli,  are  found  to  be  colored  ;  but 
this  coloration  rapidly  disappears  when  the  animal  is 
permitted  to  live,  all  the  coloring  matter  carried  by 
the  water  passing  into  the  urine."     (Charcot,  loc.  cit.) 

Heidenhain  also  varies  the  experiment  by  cauterizing 
portions  of  the  surface  of  the  kidney,  thus  suppressing 
in  the  corresponding  parts  of  the  kidney  the  secretion  of 
water  ;  in  the  parts  not  cauterized  the  coloration  affects 
the  medullary  and  cortical  portions,  and  in  those  cau- 
terized only  the  cortical,  in  this  part  only  the  convoluted 
tubes  and  ascending  branch  of  Henle'  s  loop  being  af- 
fected. 

The  object  of  the  aqueous  secretion  is  probably  only 
to  give  fluidity  and  to  carry  the  products  into  the  col- 
lecting tubes. 

Still  more  conclusive  is  the  result  of  the  injection  of 
urate  of  soda,  one  of  the  salts  found  in  normal  urine. 
In  the  experiments  of  Mr.  Heidenhain  the  urate  of  soda 
injected  in  a  concentrated  solution  is  deposited  in  the 
canaliculi  contorti,  in  the  form  of  yellow  granulations 
accumulated  in  the  lumen  of  these  tubes,  while  there  is 
not  found  in  the  glomeruli  the  slightest  trace  of  it. 

In  the  urine  of  birds,  which  is  almost  solid  from  the 
uric  acid  it  contains,  this  is  never  found  in  Bowman's 
capsule. 


CHAPTER  yill. 

THE  SIGNIFICANCE  OF  THE  EXISTENCE  OR  NON-EXISTENCE  OF 
ALBUillN  IN  THE  URINE,  AND  THE  GENERAL  CONDITIONS 
OF  ITS  OCCURRENCE  IN  HEALTH  AND  DISEASE. 

That  the  mere  presence  of  albumin  in  tlie  urine  or  its 
absence  does  not  Indicate  tliat  nephritis  exists  or  does 
not  exist  is  generally  recognized.  The  former  is,  how- 
ever, often  a  phenomenon  of  such  grave  import  that  its 
recognition  and  meaning  demand  serious  consideration. 

Albuminuria  occurs  in  urine  either  as  a  physiological 
or  pathological  event,  in  the  former  being,  however,  "in 
small  quantity,  transient,  and  compatible  with  a  perfect 
state  of  health  "  (Chateaubourg).  As  a  physiological  con- 
dition it  is  as  yet  not  generally  recognized,  but  that  it 
does  thus  occur  I  think  has  been  satisfactorily  shown. 
I  do  not  here  include  the  albuminuria  following  de- 
ranged digestion,  great  mental  or  physical  exertion, 
excesses  in  eating  or  drinking,  exposure  to  a  low  tem- 
perature, biliary  derangements,  etc.,  since,  after  these,  it 
is  the  exception  when  albumin  cannot  be  detected  by 
delicate  tests.  But  very  recent  researches  which  I  shall 
specify,  on  an  extensive  scale  and  conducted  under  the 
most  favorable  circumstances,  clearly  enough  show  that 
albumin  may  often  be  found  in  the  urine  in  the  case  of 
persons  enjoying  perfect  health,  without  any  known 
exciting  cause,  and  under  influences  of  repose,  diet,  etc., 
most  calculated  to  prevent  it,  and  that  it  often  occurs 
in  children  in  perfect  health. 

Albumin  formed  externally  to  the  kidneys,  as  that  ac- 
companying blennorrhoea,  deep  vaginitis,  and  cystitis,  or 


38  bright' S   DISEASE. 

occurring  from  blood  in  the  geuito-urinary  system  ex- 
clusive of  the  kidney,  is  to  be  eliminated  here,  as  I  refer 
only  to  renal  albumin,  and  as  all  the  varieties  of  albu- 
min found  in  the  blood '  are  to  be  found  in  the  urine 
without  important  modifications,  I  should  state  that  in 
speaking  of  renal  albumin  I  refer  to  serine,  or  the  albu- 
min of  the  blood,  and  to  globulin,  the  two  coexisting  in 
the  urine.  The  former,  however,  is  in  only  small  pro- 
portion to  the  other.  Egg  albumin  injected  into  the 
veins  passes  into  the  urine.  This  is  not  the  case,  how- 
ever, with  serum  albumin. 

For  some  time,  however,  an  idea  of  physiological 
albuminuria  has  existed.  It  was  suggested  by  Gubler  in 
I860  that  albumin  occurred  in  the  urine  of  well  per- 
sons ;  Ultzmann,  in  1870,  recognized  albumin  in  the 
urine  of  eight  young  j)ersons  in  good  health  ;  in  1873  J. 
Yogel  stated  that  he  had  for  several  years  recognized 
the  existence  of  albumin  without  appreciable  lesion  of 
any  organ.  Saundby  found  it  to  be  persistently  present 
in  the  urine  of  two  young  persons  in  perfect  health,  a 
lacteal  diet  and  repose  in  bed  causing  it  to  diminish  but 
not  to  disapj)ear. 

Dr.  G.  Johnson  regards  the  occurrence  of  albumin 
in  persons  in  "apparent"  perfect  health  as  common, 
and  reports  a  number  of  instances  in  which  it  existed  in 
notable  quantities.  In  regard  to  one  of  these  cases, 
however,  he  states : 

"1.  In  this  latent  albuminuria  without  apparent 
lesion,  if  the  cause  be  sought  some  excitement  will  al- 
ways be  found. 

"2.  That  the  presence  even  of  traces  of  albumin  in 
the  urine  is  always  pathologic  and  never  phj^siological." 

'  Hoppe-Sejler  gives  eight  groups  of  these,  nainely :  1.  Albumins;  2. 
Globulins  ;  3.  Fibrins ;  4.  Albuminates ;  5.  Acid  albumins  or  syntonin  ; 
6.  Amyloid ;  7.  Coagulated  albuminous  bodies ;  8.  Peptones.  It  is  neces- 
sary to  treat  here  only  of  tlie  first  two. 


SIGNIFICANCE   OF   ALBUMIN   IN   THE   URINE.  39 

It  is  unlikely  that  all  the  above  observers  were  mis- 
taken in  their  conclusions  that  albumin  was  found  in 
health,  but  as  their  method  of  testing  in  each  case  is  not 
given,  and  as  they  do  not  state  whether  microscopic 
examinations  were  made,  it  is  not  possible  for  us  to  say 
that  the  supposed  albumin  was  not  peptonuria,  or  that 
the  microscope  might  not  have  shown  in  some  of  the 
cases  the  existence  of  slight  nephritis.  I  have  myself 
detected,  by  Tanret's  test  especially  (the  double  iodide 
of  mercury  and  potassium),  albumin  in  the  urine  in 
numerous  cases  where  no  evidences  of  deranged  health 
existed. 

Senator,  with  every  precaution,  first  evaporating  the 
urine,  found  many  cases  of  albuminuria  in  perfect  health. 

The  experiments  and  observations,  however,  to  which 
I  have  alluded  as  being  the  most  weighty  as  showing 
the  occurrence  of  albumin  perhaps  as  a  physiological 
phenomenon,  were  conducted  by  Drs.  L.  Capitan  and 
Chateaubourg  of  Paris,  and  are  given  by  them  with 
great  precision  in  monographs  recently  published.' 

The  first  series,  as  showing  the  occurrence  of 

Albuminuria  in  Health  and  after  Food, 

consisted  in  the  examination  of  the  urine  of  98  soldiers 
of  from  twenty-one  to  twenty-five  years  of  age.  The 
examination  was  made  on  Monday,  and  the  men  had  not 
been  subjected  to  any  fatigue  the  preceding  da}^,  and 
there  had  been  no  fatiguing  exercises  nor  inarches  in 
the  morning.  The  soldiers  were  generally  from  the 
country,  and  were  without  important  previous  antece- 
dents of  illness.  The  examinations  were  made  three 
hours  after  their  mid-day  meal.    Many  of  the  specimens 

'  L.  Capitan :  Recherclies  Experimentales  et  cliniques  sur  les  Albuminuries 
Transitoires,  Paris,  1883,  and  A.  de  la  Celle  de  Chateaubourg:  Recherclies 
sur  TAlbuminurie  Physiologique.    Paris,  1883. 


40  beight's  disease. 

were  submitted  to  microscopic  examination.  Tanret's 
reagent  was  used,  the  urine  being  allowed  to  fall  upon 
it  drop  by  drop.  The  result  was  that  in  the  urine  of  54, 
no  albumin  was  found.  In  the  urine  of  20  there  was  a 
delicate  disk  showing  about  0.007  gr.  albumin  to  the 
litre.  In  the  urine  of  24,  Tanret's  solution  and  heat 
showed  0.04  to  0.08  gr.  of  albumin  to  the  litre. 

Influence    of    Digestion    upon    PJiysiological  Albu- 
minuria. 

In  July  of  this  year  Chateaubourg  examined  the  urine 
collected  at  9  p.m.  of  94  soldiers,  five  hours  after  a  meal, 
with  the  following  result.  (These  soldiers  were  the  same 
whose  urine  he  had  examined  on  waking,  after  exercise, 
etc.) 

The  urine  of  76  (or  eighty-two  per  cent.)  contained  al- 
bumin, 1  showing  it  by  heat ;  of  the  others,  9  had  a  very 
decided  cloud,  and  32  well  marked  ;  the  others  faint. 

Leube  examined  the  urine  of  119  healthy  soldiers. 
The  urine  of  digestion  showed  albumin  only  in  18  cases. 
The  tests  he  used,  however,  are  not  given,  and  the  re- 
agents usually  employed  show  albumin  only  in  con- 
siderable amount,  and  the  subjects  had  also  observed 
the  recumbent  posture  after  eating. 

Albuminuria  in  Healthy  Ohildren. 

Capitan  examined,  at  the  Hopital  des  Enfants  As- 
sistSs,  the  urine  of  97  children,  aged  from  one  year  and 
a  half  to  eighteen  years.  Sixteen  specimens  contained 
no  albumin  ;  in  38  the  albumin  was  clearly  marked, 
varying,  however,  from  a  slight  trace,  0.007  gramme  to 
the  litre,  to  0.02. 

Chateaubourg  examined  at  the  same  hospital  the  urine 
of  142  healthy  children  from  six  to  fifteen  years  of  age. 
One  hundred  and  eleven  of  the  specimens  contained  al- 


ALBUMIN   OCCUEEING   IN   THE   UEINE  IN   HEALTH.      41 

biimiii ;  in  14  cases  it  was  very  strongly  marked  ;  in  the 
others  it  existed  only  in  variously  slight  degrees. 

Great  care  v^as  taken  in  ascertaining  the  health  and 
antecedents  of  the  children. 

Rest  and  Fatigue  as  Influencing  Albuminuria  in  tJie 

Healthy. 

In  July  of  this  year  Chateaubourg  examined  the  urine 
of  120  soldiers  of  infantry.  The  subjects  were  healthy, 
free  from  any  indispositions,  and  were  from  twenty-two 
to  twenty-five  years  of  age.  The  specimens  were  taken 
at  5.30  A.M.;  the  soldiers  had  exercised  less  than  usual 
the  previous  day.  Ninety-two  specimens  contained  albu- 
min (seventy-six  per  cent.).  In  33  of  these  the  cloud- 
iness was  strongly  marked — varying  in  the  others. 

The  same  author  examined  the  urine  of  88  troopers 
after  two  hours'  severe  exercise  in  a  very  hot  sun. 
Seventy  specimens  (87.5  per  cent.)  showed  albumin  in 
various  degrees. 

The  same  month  he  examined  the  urine  of  111  foot 
soldiers,  after  a  march  of  about  eleven  miles  ;  in  100 
cases  the  urine  showed  albumin. 

On  the  whole,  the  urine  of  201  specimens  out  of  231  of 
soldiers  who  were  fatigued  showed  albumin. 

These  facts  seem  to  show  that  albumin  may  be  found 
by  proper  tests  to  exist  in  health.  I  regret  that  my  time 
and  the  fact  that  my  manuscript  is  now  being  printed 
will  not  now  permit  me  to  give  more  fully  these  admir- 
ably conducted  experiments,  the  mode  of  using  the  re- 
agents, etc.,  as  also  a  precis  of  their  other  observations 
and  experiments  in  showing  the  influences  of  heat,  cold, 
various  diseases,  etc.,  in  producing  albuminuria.  I  shall, 
however,  refer  to  them,  as  they  are  of  importance. 


42  bright' S   DISEASE. 

Tlie  Injluence  of  Severe  Intellectual  Exertion  in  Pro- 
ducing Physiological  Albuminuria. 

Chateaubourg  found  tliat  tlie  urine  of  46  out  of  50  pu- 
pils at  one  of  the  government  schools  who  were  hard  at 
work  preparing  for  examinations,  or  ninety-two  per 
cent.,  contained  albumin. 

The  Influence  of  Cold  Bathing. 

The  same  author  found  the  urine  of  37  soldiers  out  of 
53,  taken  on  rising,  to  contain  albumin.  The  same  day 
the  urine  of  all  these  soldiers,  after  a  cold  bath,  con- 
tained albumin ;  in  the  cases  that  had  previously  con- 
tained it  the  amount  being  greatly  increased,  so  as  to  be 
rendered  apparent  by  heat  and  nitric  acid. 

Chateaubourg  also  shows  that  menstruation  and 
sexual  excitement  are  often  accompanied  by  albumi- 
nuria. 

Albuminuria  produced  by  Reflex  Action. 

Capitan  also  instituted  a  series  of  experiments  show- 
ing that  transient  albuminuria  may  be  produced  by  ele- 
vating  tlie  temperature  of  the  body,  by  irritating  the 
spinal  cord  and  brain,  and  b}^  irritation  of  the  sciatic 
nerve.  Also  by  irritating  the  auditory  nerve  (by  a  series 
of  detonations),  and  the  retina  by  strong  light.  The  in- 
terpretation of  these  two  entirely  new  experiments,  ac- 
cording to  Capitan,  is  to  be  found  in  the  reflex  vaso- 
motor action  consequent  upon  violent  excitement  of  the 
special  sensibility  of  the  sensitive  nerves,  and  the  con- 
sequent general  disturbance  of  the  nervous  system  re- 
sulting therefrom.  He  has  also  produced  albuminuria 
by  irritating  the  abdominal  plexus  of  the  intestine,  by 
cutaneous  irritation  and  by  the  hypodermic  injection  of 
chloroform,  and  by  lowering  the  temperature  of  the  skin. 

The  conclusions  of  Chateaubourg  are : 


ALBUMIlSr   OCCURRING   IN   THE   URINE   IN   HEALTH.      43 

1.  Albumin  is  found  in  the  urine  of  the  majority  of 
healthy  persons,  more  or  less  abundantly,  and  ti-ansient 
in  its  character. 

2.  Rest  in  bed  has  a  clearly  marked  influence  in  di- 
minishing the  amount  of  albumin  excreted. 

3.  Bodily  fatigue  greatly  influences  the  production  of 
physiological  and  transient  albuminuria. 

4.  Intellectual  labor  augments  with  most  people  the 
quantity  of  albumin  existing  in  the  urine. 

5.  Cold  bathing  exerts  considerable  influence  in  in- 
creasing physiological  albuminuria. 

6.  Sexual  excitement  and  menstruation  manifestly  af- 
fect albuminuria  in  the  healthy. 

7.  Albuminuria  is  as  frequent  in  children  as  in  adults, 
but  the  quantity  of  albumin  excreted  is  less. 

8.  Digestion,  if  accompanied  by  rest,  does  not  exert 
much  influence  upon  physiological  albuminuria. 

These  investigations  are  of  practical  importance,  as 
the  discovery  of  albumin,  which  may  often  be  made  by 
improved  means  of  testing,  where  formerly  it  could  not, 
is  calculated,  unless  its  significance  be  understood,  to 
create  undue  anxiety  on  the  part  of  the  physician,  but 
its  real  meaning  understood,  and  with  a  microscopic 
examination,  the  physician  is  in  a  position  to  reassure 
his  patient  and  to  avoid  the  error  of  unnecessarily  ener- 
getic measures  of  relief  from  dangers  which  do  not 
exist.  The  microscope  is  in  doubtful  cases  the  only 
reliable  test  whether  nephritis  exists. 

I  think,  however,  so  far  as  the  presence  of  albumin  is 
concerned,  that  when  it  exists  in  such  minute  quantities 
that  it  cannot  be  detected  by  nitric  acid,  it  is  not  of 
much  practical  importance  as  indicating  the  existence 
of  nephritis. 

Albumin,  as  a  pathological  condition,  may  be  pro- 
duced by  numerous  causes  other  than  nephritis.  The 
influence  of  pyrexia  in  producing  it  is  well  known,  and 


44  beight's  disease. 

indeed  it  is  almost  always  present  in  severe  pyretic 
conditions. 

Dr.  Calvin  Ellis'  has,  in  an  interesting  monograph, 
compiled  a  table  enumerating  a  large  number  of  condi- 
tions that  may  produce  albuminous  urine. 

Albumin  may  appear  in  the  urine  from  the  imperfect 
digestion  of  food.  Dr.  Brunton  gives  an  account  of  a 
patient  in  whose  case  albuminous  urine  invariably  fol- 
lowed the  use  of  fat  or  animal  food  eaten  in  the  morn- 
ing. Taken  at  night,  these  did  not  produce  albumin. 
The  patient  suffered  greatly  from  indigestion,  particu- 
larly acidity.  Treatment  which  improved  the  digestion 
relieved,  without  curing,  the  albuminuria,  which  would 
disappear  after  the  use  of  farinaceous  food  exclusively. 
These  phenomena,  with  the  fact  that  albumin  coagu- 
lated only  at  a  high  temperature,  176°  to  180°,  led  Dr. 
Brunton  to  conclude  that  in  this  case  it  was  not  serum 
albumin,  but  was  of  the  same  nature  as  egg  albumin, 
owing,  as  he  thought,  to  imperfect  digestion  of  albu- 
minous substances  from  imperfect  pancreatic  digestion. 
The  non-assimilation  of  albumin  in  the  stomach  or  intes- 
tinal canal,  in  certain  cases,  has  been  repeatedly  shown 
by  Drs.  Parkes,  Pavy,  C.  Bernard,  Stockvis,  Gubler,  and 
others,  albumin  in  these  cases  being  found  in  the  urine. 
Christison  gives  one  case  in  which  cheese  always  pro- 
duced albumin.  These  forms  of  albumin  are,  however, 
unlike  serum  albumin  ;  they  are  diffusible  through  ani- 
mal membranes,  while  serum  albumin  is  not,  and  pre- 
sents, also,  other  differences.  Their  ^ction  closely  resem- 
bles that  of  egg  albumin.  These  cases  are  of  interest,  al- 
though the  substance  found  is  undoubtedly  peptonuria. 

I  have  met  with  instances  of  deranged  digestion  in 
which  I  found  serum  albumin,  and  the  albuminuria 
was  not  owing  to  nephritis.    In  most  of  these  cases  the 

'  The  Significance  of  Albumin  as  a  Symptom.     Cambridge,  1880. 


ALBUMINOUS    URINE   IN   DERANGED   HEALTH.  45 

amount  of  albumin  was  very  slight,  sometimes  not  more 
than  a  trace.  In  some  cases  the  reaction  would  be  given 
by  nitric  acid,  heat,  picric  acid,  and  the  double  iodide 
of  potassium  and  mercury,  showing  it  to  be  serum  albu- 
min ;  in  other  cases  peptonuria  alone  would  be  found. 
In  no  instance  yet,  however,  have  I  found  a  considera- 
ble amount  of  serum  albumin  from  simple  impaired 
digestion,  or  without  organic  disease  of  some  part  of 
the  system. 

Rendall  ("These  sur  Albuminurie  Alimentaire," 
Paris,  1883)  finds  that  in  lymphatic  or  nervous  subjects 
complaining  of  general  malaise,  difficulty  of  work,  etc. — 
people,  as  it  were,  half  way  between  health  and  illness — 
many  apparently  unimportant  circumstances,  and  even 
digestion,  will  be  followed  by  albuminuria  disappearing 
when  digestion  is  completed. 

Dr.  Ellis  enumerates  among  the  various  causes  capa- 
ble of  producing  albuminuria :  1.  The  irritant  poisons, 
both  those  which  establish  local  irritation  of  the  kid- 
ney, as  phosphorus,  arsenic,  cantharides,  turpentine, 
and  irritant  poisons  generally,  as  the  mineral  acids.  2. 
Disorders  of  the  circulatory  system,  as  affections  of  the 
heart,  various  fevers,  as  intermittent  or  yellow  fever, 
peritonitis,  pneumonia,  or  pleurisy.  3.  Blood-poison- 
ing with  or  without  fever,  as  ischsemia,  acute  rheuma- 
tism, typhoid  or  scarlet  fever,  diphtheria,  variola,  mea- 
sles. 4.  Affections  or  diseases  of  the  nervous  system 
or  brain,  as  convulsions,  mania,  affections  of  the  spine 
or  spinal  cord.  5.  Changes  in  the  blood,  as  in  suppu- 
ration, syphilis,  scurvy,  cholera.  6.  Lead-poisoning,  tu- 
mors or  cancerous  affections,  goitre,  interference  of  the 
functions  of  the  skin  by  cold,  burns,  from  varnishing 
the  skin  with  gum  arable. 

He  enumerates  one  hundred  and  twenty-four  condi- 
tions, exclusive  of  nephritis,  which  may  produce  albu- 
minuria.    Many  of  the  causes,  however,  are  similar  in 


46  beight's  disease. 

their  character  and  belong  to  the  same  genns,  as  for  ex- 
ample a  number  of  varieties  of  fever,  several  varieties 
of  affections  of  the  spinal  cord,  etc.  I  will  add  to  the 
list  of  irritants  one  which  I  have  not  heretofore  seen 
mentioned,  namely,  ginger,  which  in  large  doses  is  capa- 
ble of  producing  intense  albuminuria,  ischuria,  and  renal 
inflammation. 

The  direct  cause  of  albuminuria  other  than  physio- 
logical, is  some  abnormal  condition  of  the  circulatory 
process  of  the  kidney.  Until  recently  the  theory  has 
been  generally  accepted  that  albuminuria  was  produced 
by  some  cause  leading  to  increased  rapidity  of  the  cir- 
culation within  the  glomerulus  ;  in  a  word,  it  has  been 
regarded  "  as  a  general  law  that  the  walls  of  capillaries 
permit  the  exudation  of  transudates  in  a  larger  propor- 
tion if  the  blood-pressure  in  these  vessels  be  augmented." 
The  experiments  of  Ludwig  and  Paschutin  show,  how- 
ever, that  this  is  not  the  case.  A  summary  of  these  ex- 
periments may  be  found  in  Charcot  {Legons  sur  VAlhu- 
minurie).  The  experiments  of  Overbeck  and  of  Groll 
and  of  Stockvis,  detailed  in  the  same  work,  also  show 
that  with  diminished  pressure  or  swiftness  of  the  arterial 
current  through  the  glomerulus,  albumin  is  secreted, 
while  on  the  other  hand,  increased  pressure  with  in- 
creased rapidity  result  in  increased  secretion  of  urine 
and  an  absence  of  albumin. 

What  is  observed  in  interstitial  nephritis  with  hyper- 
trophy of  the  heart  seems  to  be  opposed  to  the  above 
statements.  But  it  should  be  observed  that  in  inter- 
stitial nephritis  the  albuminuria  which  accompanies 
the  polyuria  is  not  the  consequence  of  the  increased 
pressure  in  certain  glomeruli  which  have  remained 
healthy,  but  of  obstacles  to  the  circulation  producing 
increased  pressure  or  diminished  velocity  in  the  altered 
glomeruli. 

In  venous  stasis  there  is  reason  to  believe  that  the 


METHOD  OF  SECRETION  OF  ALBUMIN  IN  THE  URINE.     47 

venous  reflex  takes  place  with  difiiculty  in  the  glome- 
ruli, for  in  spite  of  the  absence  of  valves,  venous  injec- 
tions reach  the  glomeruli  very  imperfectly.  On  the 
other  part,  the  afferent  vein  is  placed  between  two  sys- 
tems of  capillaries — an  unfavorable  condition  for  the 
return  of  venous  blood  ;  it  is  therefore  probable  that, 
in  spite  of  the  venous  stasis,  the  pressure  is  diminished 
in  the  glomerulus.  The  important  point,  however,  or 
one  which  cannot  be  contested,  is  the  diminished  veloc- 
ity. Thus  in  all  cases  of  local  or  general  disturbances 
of  the  circulation  which  determine  albuminuria,  it  is 
neither  the  augmentation  nor  diminution  of  the  blood- 
pressure  within  the  glomerulus  that  is  to  be  regarded 
as  the  cause  ;  it  is  the  diminution  in  the  velocity  of  the 
blood-current  or  the  prolonged  sojourn  of  the  slightly 
oxygenated  blood  in  the  renal  capillaries.  We  here 
find,  then,  the  conditions  of  anoxaemia  of  the  epithelia 
of  the  glomerulus  that  we  have  heretofore  shown  the  im- 
portance of  as  being  unfavorable  to  the  urinary  secre- 
tion. Then  it  is  these  same  conditions  that  preside  over 
the  secretion  of  albumin,  and  this  circumstance  explains 
this  remarkable  fact,  that  in  albuminuria  connected  with 
disturbances  of  the  circulation  the  urine  is  rare  at  the 
same  time  it  is  albuminous. 

The  theory  that  albumin  makes  its  way  through  the 
capillary  plexus  and  the  basement  membrane  when 
there  is  great  congestion  is  erroneous.  Many  authors 
state  that  in  parenchymatous  nephritis  where  the 
epithelia  are  perished  there  is  a  constant  leakage  through 
the  basement  membrane  of  the  tubules.  But  the  albu- 
min must  then  make  its  way  through  the  blood-vessels 
and  structureless  membrane.  I  have  shown,  too,  that 
when  the  epithelia  perish  they  are  invariably  replaced 
by  an  endothelial  growth.  The  albumin  would  then 
have  three  layers  of  tissue,  unlike  in  their  formation,  to 
traverse. 


48  bright' S   DISEASE. 

It  has  been  repeatedly  demonstrated  also  that  the  albu- 
min of  the  blood  cannot  transude,  under  ordinary  cir- 
cumstances, animal  membrane.  The  urine  and  albumin 
are  in  all  cases  affected,  as  is  easily  shown,  by  all  varia- 
tions of  the  arterial  or  venous  circulation  of  the  kidney, 
and  serum  albumin  in  the  urine  cannot  exist  without 
these  variations.  And  it  is  indeed  within  the  capsule  of 
Bowman  that  albumin  is  transuded  or  secreted.  In  the 
language  of  Charcot,  "numerous  cases  may  be  cited  in 
which  albumin  is  found  in  the  urine  without  any  ap- 
preciable lesions  in  the  epithelia ;  and  inversely  there 
exist  many  observations  where  the  alteration  of  the 
epithelia  was  undeniable,  and  where,  nevertheless,  albu- 
min was  completely  absent."  ' 

Having  stated  the  general  conditions  under  which 
albumin  is  found  in  the  urine,  I  will  briefly  consider 

'  Charcot,  loc.  cit.,  p.  51. 


CHAPTER  IX. 

THE  TESTS  FOR  ALBUMIN  IN  THE  URINE. 

It  may  be  stated  that  the  normal  specific  gravity  of 
the  urine  ranges  from  1015  to  1022.  The  albuminous 
urine  of  nephritis,  unless  where  acute  hemorrhagic 
nephritis  exists,  or  an  excess  of  urates,  is  usually  clear 
or  pale-looking,  sometimes  having  a  soapy  appearance. 
It  froths  easily  upon  shaking  or  stirring  and  remains 
frothy  much  longer  than  normal  urine. 

The  well-known  tests,  heat  and  nitric  acid,  though  not 
always  to  be  relied  upon  for  the  detection  of  very  small 
quantities  of  albumin,  will  be  generally  found  easily 
available,  and  with  proper  restrictions  accurate  under 
ordinary  circumstances. 

To  Test  for  Albumin  by  Heat. 

It  is  important  that  the  test-tubes  used  should  be 
perfectly  clean,  or  an  alkali  albuminate  may  be  formed. 
The  test-tube  may  be  filled  half  full  of  urine  and  the 
flame  of  a  spirit  lamp  applied  to  the  upper  third.  If  ap- 
plied to  the  bottom,  violent  succession  and  running  over 
of  the  liquid  is  liable  to  result.  If  the  urine  be  neutral 
or  alkaline,  it  should  be  made  acid  by  adding  a  few 
drops  of  acetic  or  citric  acid,  since  otherwise,  if  albumin 
were  present  in  small  quantity  it  would  escape  detec- 
tion. If  albumin  be  present  a  moderate  degree  of  heat, 
140°  F.,  soon  produces  an  opaline  appearance  which 
becomes  opaque  if  a  large  percentage  of  albumin  be 
present. 


50  bkight's  disease. 

The  presence  of  the  earthy  phosphates  may  produce 
opacity  by  heat,  simulating  that  produced  by  the  pres- 
ence of  albumin.  The  opacity  thus  produced  rapidly 
disappears  upon  the  addition  of  nitric  acid.  Care  must 
be  taken  not  to  add  too  much  acid,  or  an  acid  albumi- 
nate may  be  formed  if  albumin  be  present,  which  does 
not  coagulate  by  heat.  The  urine,  if  turbid,  should 
be  filtered,  but  if  this  process  do  not  clear  it  up  it 
should  be  boiled  with  a  fourth  part  of  strong  caustic  of 
potash  solution  and  filtered.  If  not  quite  clear  a  few 
drops  of  magnesian  fluid  should  be  added  and  filtration 
again  employed.  Then  when  it  is  acidulated  with  a 
small  quantity  of  acetic  acid,  boiling  will  make  the 
turbidity  from  the  presence  of  albumin  still  more  per- 
ceptible. 

In  employing  the  chemical  tests,  particularly  the  test 
by  the  double  iodide  of  mercury  and  potassium,  a  clear 
and  even  bright  light  is  indispensable.  Where  only 
a  very  minute  quantity  of  albumin  is  present,  it  is  some- 
times, without  this,  impossible  to  recognize  the  slight 
turbidity  produced  by  this  reagent  when  dropped  into 
the  urine. 

The  Niteic  Acid  Test 

is  best  applied  as  follows :  pour  into  the  bottom  of  a 
test-tube  half  a  drachm  of  nitric  acid,  and  holding  it 
obliquely,  allow  the  urine  to  trickle  very  slowly  down 
upon  it  through  a  pipette.  The  difiiculty  of  regulating 
the  exact  quantity  of  urine  which  it  is  desired  to  let 
flow  upon  the  acid  is  easily  overcome  by  attaching  to 
the  top  of  the  pipette  an  india-rubber  bulb,  such  as  is 
used  on  medicine-droppers.  The  quantity  can,  by  pres- 
sure on  the  bulb,  be  perfectly  regulated.  Then  holding 
up  the  tube  in  front  of  a  dark  ground  furnished  by  a 
book,  just  below  the  upper  edge  of  the  latter,  so  that 
the  light  may  fall  obliquely  upon  the  line  of  junction 


TESTS   FOE   ALBUMITS"   IN   THE   URINE,  51 

of  the  two  Huids,  while  at  the  same  time  it  is  seen 
against  the  dark  ground,  if  albumin  be  present,  be- 
tween the  urine  and  nitric  acid  there  is  seen  a  sharp 
opalescent  line  of  demarcation,  forming  the  bottom  of 
the  coagulable  layer,  which  stratum  is  of  a  greater  or 
less  thickness  according  to  the  amount  of  albumin  pres- 
ent. If  no  albumin  be  present,  the  lower  stratum  of 
urine  forms  a  narrow,  dark-brown  ring.  This  is  due  to 
the  action  of  the  acid  upon  the  coloring  matters  of  the 
urine. 

If  the  acid  or  mixed  urates  be  present  in  excess, 
a  similar  appearance  is  produced  by  the  nitric  acid. 
The  zone  is  whitish  and  the  lower  border  sharp,  but 
the  upper  part  is  more  irregular.  This  can  be  easily 
distinguished  from  albumin  by  its  disappearing  on 
heating.  If  the  urine  be  warmed  before  the  nitric  acid 
is  employed,  the  white  zone  is  not  produced.  Where 
albumin  has  been  present  in  very  small  amount,  I  have 
found  it  impossible  to  detect  it  by  nitric  acid  until  I 
boiled  the  urine  with  one-fourth  its  bulk  of  liquor  potas- 
Sce  and  filtered.  It  is  unnecessary  to  acidulate  the 
urine  on  testing  it  with  the  nitric  acid. 

"In  severe  cases  of  fever  a  small  quantity  of  albumin 
wiU  coexist  with  an  excess  of  acid  urates.  In  these 
cases  the  urine  is  of  high  specific  gravity,  and  the  line  of 
albumin  lying  immediately  on  the  acids  may  be  ob- 
scured by  the  broader  band  and  cloud  of  urates." 
(Tyson.) 

The  presence  of  the  resin  of  copaiba  in  the  urine  may 
also  produce,  with  nitric  acid,  the  white  zone.  It  may 
be  distinguished  by  its  disappearing  readily  upon  the 
addition  of  alcohol. 

Although  the  above  tests  are  conclusive  enough  when 
a  considerable  or  moderate  amount  of  albumin  exists, 
there  are  instances  when  they  may  not  detect  the  pres- 
ence of  minute  quantities. 


52  bright' S   DISEASE. 

!N'itric  acid,  however,  does  not  always  detect  the  exist- 
ence of  albumin.  I  cannot  say  that  the  brine  test  is 
more  accurate  ;  ordinarily  it  does  not  show  the  white 
zone  in  such  sharp  contour  ;  but  in  one  instance  re- 
cently it  has  clearly  shown  the  existence  of  albumin 
when  nitric  acid  could  not  in  any  manner  be  made  to 
show  it.  The  presence  of  albumin  was  also  shown  by 
the  double  iodide  of  mercury  and  potassium,  and  by 
chromic  and  picric  acid,  but  not  by  heat.  The  specific 
gravity  of  this  urine  was  1032.  It  contained  about  one- 
fortieth  of  one  per  cent,  of  sugar,  and  crystals  of  uric 
acid  iand  oxalate  of  lime  in  abundance.  Otherwise  it 
was  normal.  This  is  the  first  instance  where  I  have 
known  the  brine  test  to  be  more  accurate  than  nitric 
acid.  Whether  the  fact  in  this  case  is  due  to  the  pres- 
ence of  sugar  I  am  as  yet  unprepared  to  say. 


The  Brine  Test 


as  described  by  Dr.  Roberts,  of  Manchester  {Lancet, 
October  14,  1882),  is  in  many  respects  as  valuable  as, 
and  perhaps,  as  shown  above,  sometimes  more  valuable 
than  the  nitric  acid  test.  The  reagent  is  prepared  by 
mixing  a  fluid  ounce  of  dilute  hydrochloric  acid  with  a 
pint  of  water,  saturating  with  common  salt,  and  filter- 
ing. This  solution  is  used  in  the  same  manner  as  the 
nitric  acid,  and  shows  the  same  reactions.  The  advan- 
tages of  this  reagent  are:  1.  That  it  can  be  carried 
about  with  less  inconvenience  than  fuming  nitric  acid, 
and  does  not  discolor  the  fingers  and  clothing.  2.  In 
high-colored  urine  it  does  not  produce  a  brown  tint. 
3.  Where  there  is  an  excess  of  urates  it  does  not,  like 
nitric  acid,  produce  a  white  cloud.  4.  After  the  speci- 
men of  urine  has  been  tested  by  the  brine  for  albumin, 
the  same  specimen  can  be  tested  for  sugar  by  pellets  of 
the  solid  Fehling's  test.     (See  Appendix  A.) 


TESTS   FOR  ALBUMIN   IN  THE   UKINE  53 

The  disadvantages  seem  to  be  that  "in  addition  to  al- 
bumin, acidulated  brine  precipitates  peptones,  which 
are  sometimes  present  in  urine,  so  that  occasionally  a 
slight  cloudiness  is  produced  by  the  salt  solution  where 
nitric  acid  and  boiling  (which  do  not  precipitate  pep- 
tones) produce  no  reaction." 

Tlie  nitric  acid,  however,  gives  a  better  idea  of  the 
quantity  of  albumin  present  by  the  density  of  the 
white  cloud  produced  than  does  the  brine  test. 

The  quantity  of  albumin,  if  considerable,  may  be  ap- 
proximately known  by  Heller's  nitric  acid  test. 

"If  this  zone  is  faint  and  feeble  white,  and  has  no 
lumpy  appearance,  but  is  almost  transparent  and  only 
visible  as  a  sharply  defined  band  on  a  black  back- 
ground having  the  height  of  but  2  to  3  mm.,  we  may  say 
that  albumin  is  only  present  in  small  amount  (less  than 
one-half  per  cent.,  usually  one-tenth  per  cent.).  If  this 
zone  appears  from  4  to  6  mm.  high,  snow-white,  opaque, 
and  distinctly  recognizable  without  a  black  background 
and  of  a  flocculent  appearance,  then  albumin  is  present 
in  considerable  quantity  (one-fourth  to  one-half  per 
cent.).  But  if  on  the  addition  of  the  acid  the  albumin 
appears  lumpy  and  flaky,  and  more  or  less  falls  to  the 
bottom,  and  by  stirring  with  a  glass  rod  the  urine  be- 
comes of  a  creamy  consistence,  then  albumin  is  present 
in  large  amount  (one-half  per  cent,  and  more)."  (Hof- 
mann  and  Ultzmann,  p.  87.) 

PiCEIC  AoiD 

as  a  test  for  albuminous  urine  was  first  recommended 
by  M.  Gallipe  in  the  French  medical  journals  some- 
where about  1872. 

Dr.  G-.  Johnson  treats  fully  of  this  reagent  in  the 
Lancet  of  November,  1882. 

' '  In  normal  urine  it  has  never  given  a  precipitate  or 


54  bkight's  disease. 

produced  any  other  change  than  the  slight  yellow  tinge 
due  to  the  color  of  the  solution,  the  mixture  remaining 
quite  transparent." 

"  A  saturated  aqueous  solution  may  be  quickly  made 
by  adding  about  fifty  times  the  bulk  of  boiling  distilled 
or  rain-water  to  the  powder  or  crystals.  A  portion  of  the 
acid  will  crystallize  out  on  cooling,  leaving  a  transparent 
yellow  supernatant  liquid.  The  coagulated  picrate  of 
albumin  is  soluble  in  alkalies  ;  if,  therefore,  the  urine 
be  highly  alkaline,  it  must  be  acidulated  before  adding 
the  picric  acid  solution." 

It  is  important  to  observe  that  "if  the  urine  be  tur- 
bid with  urates,  it  must  be  cleared  by  heat  before  the 
addition  of  the  picric  acid  solution." 

"  In  applying  this  test  the  urine  may  be  poured  upon 
the  acid,  which  has  been  previously  placed  in  the  test- 
tube,  or  the  urine  having  been  poured  into  the  test-tube, 
a  few  drops  of  the  acid  are  allowed  to  flow  down  the 
side  of  the  tube  while  held  in  a  sloping  position.  It 
sometimes  happens  that  when  the  amount  of  albumin 
is  very  small,  an  interval  of  some  minutes  elapses  before 
any  change  occurs  at  the  junction  of  the  two  liquids. 
IN'ow,  in  such  cases  I  have  found  that  a  mixture  of 
equal  volumes  of  the  urine  and  the  picric  acid  solution 
has  immediately  become  turbid  with  coagulated  albu- 
min. In  speedy  and  decided  action  of  the  test  upon 
urine  which  is  only  slightly  impregnated,  the  picric 
acid  solution  is  superior  to  nitric  acid.  It  should  be 
borne  in  mind  that  the  picric  acid  saturated  solution  is 
but  little  heavier  than  distilled  water,  its  specific  gravity 
being  about  1003 ;  so  that,  unlike  the  heavy  nitric  acid, 
it  tends,  when  slowly  poured  into  the  tube,  to  float  on 
the  surface  of  the  urine,  where  a  film  of  coagulated  al- 
bumin forms  at  the  junction  of  the  two  liquids." 

Unless  already  very  acid,  the  efiicacy  of  this  test  is 
greatly  increased   by  acidulating    quite  strongly   the 


TESTS   FOR  ALBUMIN   IN   THE   UEINE.  56 

urine  with  acetic  or  citric  acid.  If  the  urine  be  in  the 
slightest  degree  turbid,  it  should  be  boiled  with  one- 
fourth  the  quantity  of  liquor  potassse,  and  thoroughly 
acidulated  before  testing.  I  find  the  most  satisfactory 
way  of  employing  the  picric  acid  test,  then,  to  allow  a 
few  drops  to  trickle  down  upon  the  urine.  Turbidity 
is  at  once  produced,  which  soon  resolves  itself  into  a 
whitish  layer  upon  the  urine.  The  layer  is  less  white 
and  sharp  than  that  produced  by  nitric  acid.  I  believe 
that  picric  acid  often  shows  the  presence  of  albumin 
where  nitric  acid  fails  to  do  so. 

A  possible  source  of  error  should  always,  however, 
be  noted  relative  to  the  simulation  of  albumin  produced 
by  this  test,  namely,  that  peptones  and  the  salts  of  pot- 
ash give  the  reaction  of  albumin  with  it,  of  course 
serum  albumin  and  para-globulin  being  the  morbid  ele- 
ments ;  the  precipitate,  however,  which  picric  acid  gives 
with  the  peptones  is  easily  dissolved  by  a  low  degree 
of  heat. 

The  most  delicate  test  for  the  recognition  of  minute 
quantities  of  albumin  is 

The  Doitble  Iodide  of  Mercury  and  Potassium^ 

first  suggested  by  Tanret,  of  Troyes,  in  1872,  and  known 
as  "  Tanret' s  test." 

The  formula  for  the  preparation  of  the  precipitating 
solution  is  as  follows  : 

Potassii  iodidi 3.22  grammes. 

Hydrargyri  bichloridi 1.36  gramme. 

Aqufe  dest q.  s.  ad  100  c.  c. 

In  using  this  test  for  the  discovery  of  minute  quanti- 
ties of  albumin,  these  three  points  are  important :  1. 
That  the  urine  should  be  perfectly  clear,  being  boiled, 
if  necessary,  with  potash  and  filtered.     2.   That  it  be 


56  beight's  disease. 

well  acidulated.  3.  That  a  strong,  clear  light  be  em- 
ployed.    (See  Appendix  B.) 

Although  for  the  purposes  of  acidifying  urine  acetic 
and  citric  acids  are  indiscriminately  recommended,  I 
think  when  albumin  exists  in  minute  quantities,  citric 
acid  is  altogether  preferable. 

A  few  drops  of  the  solution  may  be  added  to  the 
urine  which,  in  case  only  a  minute  quantity  of  urine  be 
present,  shows  a  very  slight  turbidit}^,  sometimes  even 
difficult  to  recognize,  the  cloudiness  increasing  in  pro- 
portion to  the  amount  of  albumin. 

The  general  opacity  or  turbidity  has  about  the  same 
appearance  as  that  produced  by  the  phosphates  upon 
the  application  of  heat. 

If  the  solution  be  allowed  to  run  slowly,  drop  by 
drop,  along  the  sides  of  the  tube,  the  two  liquids  re- 
main separated  and  a  bluish  disk  more  or  less  thick  is 
formed. 

I  find  it  usually  preferable,  however,  to  pour  this  re- 
agent into  the  bottom  of  the  test-tube  and  allow  the  urine 
to  trickle  down  upon  it,  drop  by  drop,  along  the  side  of 
the  tube  ;  the  two  liquids  thus  remain  separated,  a  disk 
being  formed  as  just  described. 

Where  the  quantity  of  albumin  is  small,  as  much 
urine  should  be  added  as  will  equal  the  amount  of  the 
reagent.  The  cloud  or  disk  will  be  bluish-white,  bluish- 
yellow,  or  bluish ;  if  the  urine  be  heated,  the  cloudiness 
will  be  increased  and  flocculi  formed.  This  reagent  will 
show  as  small  a  quantity  of  albumin  as  .005  gramme  to 
the  litre. 

A  source  of  error  by  this  test  is  that  the  peptones 
are  precipitated  by  it,  which,  however,  disappear  by 
heat.  If  there  be  the  slightest  doubt  the  tube  should 
be  held  obliquely  and  the  disk  only  heated,  taking  care 
to  remove  the  heat  at  the  moment  of  ebullition ;  if  the 
disk  then  do  not  disappear  it  is  albumin. 


TESTS   FOR   ALBUMIN   IN   THE   URINE.  57 

In  the  urine  of  persons  who  are  taking  alkaloids  a 
precipitate  is  formed  which  will  disappear  by  the  appli- 
cation of  heat  or  njDon  adding  alcohol ;  a  precipitate  is 
given  also  when  the  urates  are  in  excess,  disappearing, 
however,  by  heat.  Mucus  also  forms  a  cloud,  but  heat 
will  cause  it  to  assume  the  form  of  filaments. 

Bodium  Tungstate, 

first  employed,  I  believe,  in  urinary  analysis  by  Dr. 
Oliver,'  of  Harrowgate,  is  according  to  him  "an  albu- 
min precipitant  of  great  delicacy,  rapid  in  operation, 
and  one,  moreover,  so  far  as  I  have  ascertained,  devoid 
of  all  objectionable  qualities."  It  is  employed  in  the 
same  manner  as  nitric  acid,  that  is,  by  allowing  it  to 
drop  into  the  urine,  or  by  letting  the  urine  trickle  down 
upon  a  convenient  quantity  of  the  reagent  in  a  small 
test-tube. 

I  have  found  this  test  a  more  sensitive  one  than  nitric 
acid,  and  am  not  able  thus  far,  from  my  own  experience 
with  it,  to  say  that  it  is  liable  to  any  fallacies.  It  is 
prepared  by  mixing  together  equal  parts  of  the  satu- 
rated solutions  of  the  tungstate  (one  in  four)  and  of 
citric  acid  (ten  in  six)  and  of  water. 

In  regard  to  the  comparative  value  of  the  various  tests, 
Dr.  Oliver's  opinion,  "as  the  result  of  many  observations 
and  experiments,"  is  that  one  part  of  albumin  may  be 
discovered  in  20,000  by  the  iodo-mercuric,  picric,  and 
tungstate  tests;  in  10,000  to  12,000  by  the  ferrocyanic 
and  the  brine  test;  and  in  6,000  to  7,000  by  the  heat 
and  nitric  test. 

Dr.  Pavy  was  the  first,  I  believe,  to  employ  in  testing 
urine  for  albumin  a  saturated  solution  of  ferrocyanide 
of  potassium,  the  urine  being  first  acidified  by  citric  acid. 

'  On  Bedside  Urine  Testing  :  Qualitative  Albumen  and  Sugar,  by  Geo. 
Oliver,  M.D.     London,  1883. 


58  bright' S   DISEASE. 

I  have  not  found  this  test,  however,  so  sensitive  as 
others.  Dr.  Pavy  has  also  introduced  pellets  of  sodic 
ferrocyanide  acidulated  by  citric  acid.  In  using,  one  is 
to  be  crushed,  put  into  the  bottom  of  a  test-tube,  and 
the  urine  poured  upon  it ;  on  agitating  vv^ithout  heat,  a 
precipitate  is  shown  if  albumin  be  present.  A  turbid- 
ity is  also  produced  if  oleo-resinous  matter  be  present. 
I  have  not  used  them  as  yet,  but  for  bedside  testing,  if 
reliable,  they  must  prove  a  great  convenience.  A  full 
account  is  given  of  them  in  the  British  Medical  Jour- 
nal^ February  17,  1883. 

The  Use  of  Test-papers. 

Dr.  Oliver '  has  recently  introduced  a  method  of  test- 
ing for  albumin  and  sugar  which  has  at  least  the  great 
advantage  of  convenience  and  neatness  as  regards  "bed- 
side testing,"  and  seems  as  accurate  and  sensitive  as 
testing  by  solutions.  He  uses  chemically  inert  filtering 
paper  soaked  in  the  reagents,  and  after  drying  cut  up 
into  test-papers.  He  employs  in  preparing  these  the 
double  iodide  of  mercury  and  potash,  sodium  tung- 
state  and  ferrocyanide  of  potassium,  citric  acid  (for 
acidifying  the  urine)  and  picric  acid. 

The  urine,  if  turbid,  must  be  cleared,  and  30  to  50 
minims  transferred  to  a  small  test-tube,  then  rendered 
strongly  acid  by  dropping  in  a  citric  paper,  which  may 
be  withdrawn  after  allowing  it  to  remain  a  few  sec- 
onds ;  or  both  the  citric  and  the  reagent  paper  may  be 
dropped  in  at  the  same  time  and  the  urine  poured  upon 
them.  If  albumin  be  present  in  a  small  quantity — e.g.^ 
below  a  sixth  or  eighth  of  one  percent. — a  whitish  cloud 
will  very  quickly  gather  about  the  paper,  and  will  col- 
lect at  the  bottom  of  the  test-tube  or  in  the  lower  half 

'Loc.  cit. 


TESTS   FOR   ALBUMIISr   ITT  THE   URUSTE.  59 

of  the  column  of  urine  ;  if  there  be  only  a  trace,  the 
opacity,  of  course,  will  be  slight,  and  will  more  readily 
be  detected  by  intercepting  the  light  by  the  hand.  Di- 
rections are  also  given  for  developing  a  zone  of  precipi- 
tation along  the  plane  of  contact  of  a  test-solution  and 
the  urine.  It  is  scarcely  possible  here  to  give  even  a 
bare  outline  of  the  details  of  Dr.  Oliver's  method,  and  I 
must  refer  the  reader  to  his  useful  little  book.  Articles 
by  him  relative  to  this  subject  may  also  be  found  in 
the  Lancet  of  January  27  and  February  3,  1883. 

The  test-papers  have  been  found  to  show  the  presence 
of  albumin  in  albuminous  urine  diluted  to  such  an  ex- 
tent that  nitric  acid  ceased  to  detect  it.  Dr.  Oliver  states 
that  the  papers  do  not  seem  to  lose  their  efficacy  even 
when  they  are  exposed  to  the  light  and  air. 

I  have  prepared  all  these  test-papers,  and  although  I 
have  as  yet  had  but  few  opportunities  of  testing  them, 
I  have  found  them  thus  far  in  the  main  satisfactory, 
the  iodo-mercuric  being  the  most  so  ;  the  papers  pre- 
pared with  the  tungstate,  however,  sometimes  fail  to 
show  albumin  when  it  is  present.  For  the  detection  of 
very  minute  quantities  of  albumin,  I  find  the  other  pro- 
cesses preferable.  Their  use  will  prove  of  the  greatest 
convenience  to  the  physician  at  a  distance  from  his 
office. 

Of  Nepheitis  without  Albumzn^. 

As  albuminuria  may  exist  without  nephritis,  so  the 
latter,  even  advancing  to  the  stage  of  cirrhosis,  may 
often  exist  without  albuminuria.  This  is  shown  in 
Chapter  XIX. 


60 


beight's  disease. 


I  will  close  this  cliapter  by  adding  the  following  table 
from  Dr.  Oliver's  work. 


o 

^ 

Tf) 

W 

t 

PL. 

E3 

i_^ 

*r^ 

<j 

o 

O 

M 

\!i 

h 

H 

M 

c« 

H 

W 

W 

H 

<1 

r  .s 


»§  +  + 


<o 

ei 

■u 

«§) 

+ 

+ 

+ 

a 

53 

H 

Pi 


^ 

H 

^ 

S 

H 

1 

P 

S 

« 

g 

(-:i 

1-^ 

g 

<! 

^^ 

§ 

ft 
1— 1 

M 

1^ 

u 

h-l 

s 

<1 

<l 

T-l 

ci 

CO 

02  ^ 


tS 


•pesn  Suiaq  g  lo  '^  'g  ^uaS^ajj 


CHAPTER  X. 

THE  IMPORTANCE  AND  SIGNIFICANCE  OF  URINARY  CASTS 

I  HAVE  endeavored  to  show  in  a  paper  contributed  to 
tlie  New  YorTc  Medical  Journal^  November,  1882,  and 
subjoin  the  following  extracts  from  it : 
■  Charcot '  thinks  that  "  the  clinical  importance  of  uri- 
nary casts  has  been  greatly  exaggerated.  They  are  not, 
as  they  have  been  called, '  faithful  messengers  announ- 
cing to  the  clinical  observer  the  anatomical  condition  of 
the  kidney.'  "  Again,  he  states  that  "hyaline  casts  may 
be  found  in  the  urine  in  normal  conditions.  This  fact, 
first  pointed  out  by  M.  Eobin,  in  1855,  has  been  con- 
firmed by  Axel  Key,  Eosenstein,  and  many  other  au- 
thors. They  are  also  met  with  in  various  other  affec- 
tions than  those  of  the  kidney,  and  even  where  there 
is  no  albuminuria.  Nothnagel  says  that  he  constantly 
found  them  in  cases  of  severe  icterus." 

My  reasons  for  believing  that  casts  are  never  found  in 
normal  conditions  of  the  kidney  are  these  : 

1.  In  a  very  large  number  of  microscopical  examina- 
tions of  urine  from  which  albumin  was  absent,  I  have 
never  in  a  single  instance  found  a  hyaline  cast  without 
finding  in  the  same  specimen  epithelia  from  the  tubules, 
with  pus.  The  two  latter  I  have  often  found,  with  or 
without  albumin,  without  finding  casts. 

2.  In  a  very  large  number  of  microscopical  examina- 
tions of  the  kidney  itself  I  never  have  found  casts  with- 
out the  presence  in  the  same  specimen  of  other  evidences 

'  Charcot :  Bright's  Disease,  p.  33.     New  York,  1878. 


62  beight's  disease. 

of  inflammation,  as  swollen  epithelia,  tliickening  of  the 
connective  tissue,  pus,  and  blood  corpuscles,  fatty  de- 
generation, etc. 

3.  I  am  confident  that  in  the  researches  I  have  made 
in  the  minute  anatomy  of  the  epithelia  of  the  kidney, 
the  results  of  which  were  published  in  the  New  YorTc 
Medical  Journal  for  June,  1882,  I  have  shown  (for  the 
first  time)  that  the  formation  of  every  cast  is  accom- 
panied by  the  destruction  of  the  epithelia  lining  the  tu- 
bule, which  lost  or  perished  epithelia  are  invariably  re- 
placed by  an  endothelial  investment,  which  had  not 
previously  existed,  of  the  structureless  membrane. 

It  is  possible  that  the  slight  importance  the  above- 
named  observers  attribute  to  the  existence  of  casts  may 
have  been  due  to  the  fact  that  the  hyaline  casts  which 
they  found  occurring  in  urine  containing  no  albumin, 
they  concluded  that  the  kidneys  were  free  from  disease. 
Epithelia  and  pus  corpuscles  also  must,  however,  have 
been  present.  As  granular,  blood,  and  epithelial  casts 
occur  only  in  croupous  nephritis,  in  which  the  urine  is, 
with  extremely  rare  exceptions,  albuminous,  albumin 
must  have  been  present  in  the  urine  containing  them. 

Again,  there  is  no  doubt  but  that  mucous  casts,  which 
have  no  significance,  are  often  mistaken  for  hyaline. 
The  latter  are  somewhat  refractive,  with  straight  edges, 
sometimes  with  minute  granulations,  and  assuming  the 
shape  of  the  tubules  in  which  they  are  formed. 

The  mucous  cast  has  precisely  the  same  shape,  though 
it  is  usually  a  little  narrower  ;  "sometimes  their  resem- 
blance to  casts  is  even  closer  in  consequence  of  precipi- 
tation upon  them  of  granular  urates,  or  amorphous 
phosphate  of  lime."  '  This  granular  deposit,  however, 
may  be  recognized  by  its  incrusting  everything  in  the 
urine,  and  forming  a  deposit  of  its  own  (Tyson).     Often 

'Tyson;   Bright's  Disease,  p. 75.     Philadelphia,  1881. 


DIAGNOSIS   OF   HYALINE   AND   MUCOUS   CASTS. 


63 


micrococci  will  be  found  adhering  to  ifc,  closely  resem- 
bling the  slightly  grannlar  appearance  of  the  hyaline 
cast.  The  most  important  points  of  diagnosis  are  that 
the  mucous  casts  are  usuallj^  longer  and  more  convoluted, 
or  branching,  more  delicate,  and  especially  that  they  are 
invariably,  though  sometimes  very  faintly,  striated, 
which  is  never  the  case  with  the  hyaline  cast. 

The  general  appearances  of  these  two  varieties  of  cast 
are  shown  by  the  following  drawings  : 


Fig.  8. — Hyaline  Casmb. — u,  from  uouvuiutcd  mbule  of  the  second  order  ;  b,  from  the  nar- 
row portion  of  the  loop  tubules  ;  c,  from  a  straight  collecting  tubule.  (Magnified  5U0  diame- 
ters.) 


^  Fig.  9. — Mucous  Casts  from  straight  collecting  tubule  with  branches,  and  from  the  narrow 
and  broad  portions  of  convoluted  tubules ;  A  shows  a  mucous  cast  with  micrococci  adherent. 
(Magnified  500  diameters.) 

The  mucous  cast  is  not  an  inflammatory  product. 
Tyson'  gives  it  as  his  experience  that,  while  he  has 
found,  "  in  a  very  few  instances,  casts  in  urine  in  which 


'Op.  cit.,  p.  75. 


64  bright' S   DISEASE. 

there  was  at  tlie  same  time  no  albumen,"  lie  never  has 
found  true  casts  in  urine  from  what  he  considers  nor- 
mal kidneys. 

Heitzmann/  a  most  accurate  observer,  says  in  refer- 
ence to  the  non-existence  of  casts  in  normal  conditions  of 
the  urine  :  "  Reliable  observers  have  seen  casts  without 
any  albumen  in  the  urine,  and  it  has  been  asserted  that 
mere  hypersemia  of  the  kidneys  may  suffice  to  throw 
casts  into  the  urine  without  any  evil  consequences — for 
instance,  after  treatment  with  large  doses  of  iodide  of 
potasJi.  The  former  assertion  I  can  corroborate,  the 
latter  is  not  in  concurrence  with  what  I  have  seen  ;  the 
casts  surely  indicate  nephritis,  and  the  greater  their 
number  the  more  serious  is  the  disease." 

Dr.  G.  Johnson  also  says  :  "  It  is  certain  that  neither 
renal  gland  cells  (epithelia — Atjthge)  nor  tube  casts  are 
ever  found  in  normal  urine." 

'  Op.  cit.,  p.  804. 


CHAPTER  XI. 

NATURE  AND  MODE  OF  FORMATION  OP  URINARY  CASTS. 

I  BELIEVE  that  casts  are  invariably  an  albuminous 
exudate  into  the  tubules  from  the  surrounding  capil- 
laries. They  are  protein  in  their  character,  and  are 
always  the  result  of  oedematous  infiltration,  or  of  in- 
flammation ;  they  saturate  the  epithelium,  and  distend 
it,  and  lead  to  its  partial  or  entire  destruction.     That 


Fig.  10. — Acute  Croupous  Nephritis  showing  Exudate.  (Magnified  500  diameters.) — 
A,  longitudinal  section  of  convoluted  tubule ;  B,  epithelia,  enormously  swollen,  filled  with 
large  and  small  droplets  of  exudate — epithelia  with  many  coarse  granulations ;  C,  broken- 
down  epithelia  and  droplets  ;  D,  thickened  connective  tissue. 

albuminous  exudations  are  common  in  nephritis  is 
easily  enough  shown  by  their  frequent  occurrence  in 
the  capsule  of  the  glomeruli.  Cornil  finds  this  exuda- 
tion coagulated  sometimes  in  Bowman's  capsule  after 
poisoning  from  cantharidine,  and  also  in  the  convo- 
luted tubules.  He  finds  the  exudate  in  the  lumen  of 
the  tubules,  sometimes  having  assumed  the  form  of 
cylinders,  and  sometimes  constituting  droplets  either 


66 


bright' S   DISEASE. 


free  in  the  lumen  or  infiltrating  tlie  epithelia.  He  also 
gives  drawings  representing  droplets  free  and  in  the 
epithelium. 

I  have  myself  frequently  observed  these  droplets  of 
exudate  in  nephritis. 


D-'^ri 


Pig.  11. — Acute  Ceoupous  Nephritis. — Magnified  500  diameters.  A  longitudinal  section 
of  convoluted  tubule  filled  with  droplets  of  exudate,  constituting  an  incipient  cast ;  B,  trans- 
verse section  showing  incipient  cast  (very  seldom  seen)  surrounded  by  endothelia  ;  C,  straight 
tubule  with  coarsely  granular  epithelia,  the  lower  part  filled  with  broken-down  epithelia, 
gi-anular  matter,  and  nuclei ;  D,  irregular  tubules ;  E,  cross  section  of  ascending  and  de- 
scending portion  of  tubules,  with  cloudy  swelling  ;  F,  empty  tubule  ;  G,  inflammatory  cor- 
puscles ;  H,  small  limb  of  Henle's  loop. 

Figs.  10  and  11  show  the  changes  which  accompany 
the  exudation  in  a  case  of  acute  croupous  nephritis. 
The  exudate  in  this  case  is  of  a  hyaline  nature. 


FORMATION   OF    URINARY   CASTS.  67 

Fig.  18,  F^  taken  from  a  case  of  clironic  croupous 
7iepliritis,  shows  the  conversion  of  the  epithelia  into 
amyloid  corpuscles,  or  the  process  by  which  waxy  casts 
are  formed. 

Cornil  says:  "We  have  here  to  do  with  a  sort  of 
pathological  secretion  from  the  cells  of  the  convoluted 
tubules,  which  obtain  the  material  for  the  exudation 
from  the  neighboring  capillaries,  and  then  pour  it  out 
into  the  cavity  of  the  tubule.  It  is  imxjossible,  in  fact, 
for  the  liquid  to  pass  directly  from  the  capillary  vessels 
into  the  cavity  of  the  tubule,  for  the  protoplasm  of  the 
cells  forms  an  uninterrupted  homogeneous  layer  in  the 
convoluted  tubes,  and  the  cells  leave  no  empty  space 
between  them.  They  remain  in  their  places  without 
being  in  the  very  least  disintegrated.  This  is  a  fact 
which  is  of  some  importance  to  notice  at  once,  as  we 
shall  meet  with  it  again  very  frequently  in  considering 
albuminous  nephritis  in  man.  In  all  kidneys  absolutely 
fresh  and  well  preserved,  obtained  from  cases  of  albumi- 
nous nephritis,  the  cells  of  the  convoluted  tubules  re- 
main attached  to  the  wall  of  the  tubule.  The  term 
desquamative  nephritis,  then,  appears  to  us  not  to  be 
justified,  for  there  is  desquamation  of  the  cells  only  in 
the  straight  tubules,  the  part  of  the  kidney  which  is 
least  important  in  regard  to  albuminous  nephritis. 

..  .  .  "Thus  the  subacute  nephritis  produced  by 
cantharidine  gives  rise  to  the  series  of  modifications  in 
the  cells  of  the  convoluted  tubules,  and  to  the  exuda- 
tion through  these  cells,  which  is  comparable  to  a  se- 
cretion, while  at  the  same  time  consecutive  fatty  degen- 
eration is  to  be  observed."  ' 

I  here  quote  the  portion  of  my  paper  referred  to  in 
Chapter  II.  which  relates  to  the  nature  and  formation 
of  casts. 

'  The  Practitioner,  vol.  xxvii.,  No.  iv.,  October,  1881,  p.  24G. 


68  bkight's  disease. 

We  do  not  yet  know  what  the  mass  composing  a  cast 
really  is.  This  much,  however,  is  certain,  that  casts  are 
proteinates  and  formations  of  an  albuminous  or  fibri- 
nous exudate  sprung  from  the  blood-vessels.  This  exu- 
date, before  it  reaches  the  central  caliber  of  the  tubule, 
necessarily  must  saturate  the  intervening  epithelia, 
whose  structure  is  completely  destroyed  by  this  pro- 
cess. It  is  not  my  purpose  to  dwell  upon  the  origin  of 
casts,  but,  from  what  I  have  seen,  I  cannot  concur  with 
Oedmansson '  in  the  opinion  that  every  cast  should  be 
regarded  as  a  product  of  secretion  furnished  by  the  epi- 
thelium. I  am  sure  that  the  epithelia  perish  in  the  for- 
mation of  the  cast.  N'either  can  I  agree  with  Charcot  ^ 
in  the  opinion  that  some  (certain  granular)  casts  are 
made  up  of  broken-down  epithelial  cells,  others  (hya- 
line and  some  granular)  of  an  albuminous  substance, 
while  epithelial  casts  are  agglomerations  of  epithelial 
cells  more  or  less  altered. 

Bartels*  insists  that,  in  every  case  in  which  he  has 
examined  microscopically  thin  sections  of  diseased  kid- 
neys whose  tubules  were  blocked  by  the  dark  granular 
casts,  the  tubules  invariably  exhibited  an  epithelial 
lining,  reconciling  this  fact  with  his  view  by  admitting 
that  the  theory  of  Key  and  Bayer,  that  the  epithelium 
thus  shed  is  rapidly  reproduced,  may  be  correct. 

From  my  observations  it  is  obvious  that  the  last 
three  writers  have  regarded  the  endothelia,  as  I  have 
described  them,  as  epithelia. 

Nevertheless,  whenever  we  find  a  cast  within  a  tu- 
bule, especially  in  transverse  sections  of  the  tubule,  we 
almost  invariably  see  a  wreath  of  irregularly  spindle- 
shaped,  .partly  nucleated  bodies,  which  I  am  sure  are 

'  Bartels :  von  Ziemssen's  Cyclopaedia,  vol.  xv.,  p.  84. 
'^  Charcot :  Bright's  Disease.     Millard's  translation,  p.  29  et  seq.  ;  quoted 
by  Tyson.     New  York,  1878. 

2  Bartels,  op.  cit. ,  pp.  84-86 ;  quoted  by  Tyson,  on  Bright's  Disease. 


FOKMATION   OF   FRINAKY   CASTS. 


69 


nothing  but  the  lining  endothelia  of  the  structureless 
membrane. 

This  wreath  around  the  cast  may  be  easily  recognized 
by  any  good  observer.  Dr.  Alfred  M:a,yer,^  of  New 
York,  gives  illustrations  of  these  wreaths,  which  evi- 
dently are  drawn  with  the  greatest  accuracy  ;  but  he 
does  not  realize  at  all  their  character  or  significance, 


Fig.  12. — Convoluted  Tubule  feom  a  Human  Kidney  affected  with  Acute  Croup- 
ous Nephbitis.  (Oblique  section — magnified  1,200  diameters.) — C,  hyaline  cast;  B.  swollen 
and  disintegi'ated  epithelia  participating  in  the  formation  of  the  cast ;  E,  wreath  of  endo- 
thelia :  /,  interstitial  connective  tissue. 

for  he  suggests  that  they  are  constructed  either  of  rem- 
nants of  the  former  epithelia,  of  which  a  large  portion 
has  been  destroyed  in  the  formation  of  the  cast,  or  that 
they  may  be  newly  formed  epithelia.  In  both  these 
views  he  is  mistaken.  The  epithelia  are  certainly  gone, 
entering  in  a  considerably  swollen  condition  the  mass 
of  the  cast ;  but  what  is  behind  the  cast  is  not  newly 

'  TJntersuchungen  iiber  acute  Nierenentziinduiig :  Sitzungsb.  d.  Akad. 
d.  Wissenscli,  zu  WJen,  1877. 


70  bright' S   DISEASE. 

formed  epithelia,  but  merely  the  endothelial  invest- 
ment of  the  structureless  layer,  considerably  increased 
in  size.  Not  infrequently  we  see  widened  urinary  tu- 
bules, as  a  rule,  of  the  convoluted  variety,  entirely 
destitute  of  epithelia ;  or  we  see  such  tubules  contain- 
ing a  cast  broader  in  its  diameter  than  the  caliber  of 
the  tubule  would  be  if  the  epithelial  layer  were  present. 
The  latter  feature  is  explicable  by  the  fact  that  casts 
may  be  carried  into  tubules  far  distant  from  the  place 
of  their  origin — into  tubules,  besides,  which  have  been 
previously  deprived  of  their  epithelia.  There  is  no  co- 
gent necessity  whatever  for  the  conclusion  that  casts 
may  form  in  tubules  after  these  have  lost  their  epi- 
thelia. In  neither  of  these  instances  shall  we  ever  miss 
the  endothelial  investment,  although  this  is  often  found 
in  a  mutilated  or  imperfectly  developed  condition. 

That  the  "cells"  or  epithelia  do^  however,  often  des- 
quamate under  these  circumstances  I  have  been  able 
repeatedly  to  observe.  In  an  advanced  stage  of  the  ex- 
udative process  they  are  entirely  desquamated  or  de- 
stroyed. The  theory  of  Cornil  that  the  epithelia  are 
engaged  in  the  exudative  process  is  not  an  unlikely 
one. 

Usually  the  epithelia  enter  into  the  formation  of  the 
cast.  Sometimes  the  whole  of  the  epithelia,  except  the 
nuclei,  are  destroyed  entering  into  its  composition  ; 
these  and  other  undestroyed  elements  of  the  epithelia 
forming  the  granular  cast.  In  the  language  of  Meyer  : 
"The  casts  are  products  of  an  albuminous  exudation 
from  the  blood-vessels  plus  the  swollen  up  and  de- 
stroyed epithelia." 

I  think  there  is  no  doubt  but  that  casts  are  never 
found  at  the  source  of  their  formation  without  partial 
and  almost  always  complete  destruction  of  the  epithelia 
in  the  tubule.  When  a  fully  formed  cast  is  found  sur- 
rounded by  epithelia,  It  may  be  taken  for  granted  that 


FORMATION   OF   URINARY   CASTS. 


71 


it  has  been  carried  into  the  place  it  occupies  from  some 
other  locality.  The  epithelial  and  blood  casts  are  sim- 
ply hyaline  casts  with  blood-corpuscles  or  portions  of 
or  entire  epithelia  adherent.  The  yellow  are  the  result 
of  imbibition  of  the  coloring  matter  of  the  blood,  while 
the  waxy  and  fatty  casts  have  undergone  a  waxy  or 
fatty  degeneration,  or  rather  this  degeneration  has 
taken  place  in  the  epithelia. 


Fig.  13. — Vabious  Forms  and  Kinds  of  Casts. — Magnified  500  diameters,    a,  granular;  6 
fatty  ;  c,  epithelial ;  d,  blood  ;  e,  waxy. 

"The  varieties  of  tube  casts  may  be  comprised  in 
six,  viz.  :  hyaline,  granular,  epithelial,  blood,  fatty, 
and  w^axy  casts."     (Heitzmann.) 

Epithelial  and  blood  casts  indicate  acute  croupous 
nephritis.  Hyaline  casts  are  found  mostly  in  intersti- 
tial nephritis,  most  frequently  in  the  chronic  form. 

Granular,  waxy,  and  fatty  casts  are  seldom  found 
except  in  chronic  croupous  nephritis. 


72  bright' S   DISEASE. 

The  sizes  and  forms  of  the  casts  vary  greatly.  Owing 
to  the  tendency  of  the  albuminoid  matter  to  contract 
they  sometimes  present  convolutions  like  a  corkscrew. 
They  will  be  broad,  narrow,  straight,  or  convoluted, 
according  to  the  portion  of  the  tubules  from  which  they 
arise.  I  present  a  few  typical  shapes  ;  they  are  often 
broken. 

For  hyaline  casts  see  Fig.  8. 

The  waxy  cast  is  highly  refractive  and  is  often 
notched.  It  always  indicates  chronic  and  deep-seated 
renal  affection. 

The  granular  cast  is  also  unfavorable  as  indicating 
long-existing  nephritis.  Fatty  and  hyaline  casts  can 
occur  in  acute  nephritis. 


CHAPTER  XII. 

GENERAL  DIRECTIONS  FOR  EXAMINING  THE  URINE  FOR  CASTS 
AND  KIDNEY  EPITHELIA. 

These  directions  will  also  apply  to  other  substances 
in  the  urine. 

I  think  the  best  power  for  ordinary  examinations  for 
epithelia,  tubules,  pus,  etc.,  is  500.  I  may  add  that 
the  objective  should  be  that  of  a  good  maker,  and  the 
microscope  should  have  a  fine  adjustment.  The  urine 
having  been  allowed  to  stand  long  enough,  a  small  drop 
should  be  placed  on  a  glass  slide,  most  easily  by  means 
of  a  small  camel' s-hair  brush  ;  over  this  is  to  be  placed 
a  thin  glass  cover. 

If  the  amount  of  sediment  be  very  slight,  as  it  usually 
is  in  chronic  interstitial  nephritis,  it  is  often  necessary 
to  examine  several  drops  before  the  assurance  is  reached 
of  the  absence  or  presence  of  casts,  which  in  this  form 
especially  are  usually  very  scanty,  and  sometimes  en- 
tirely absent. 

Some  authors  recommend  slides  with  concave  depres- 
sions for  the  examination  of  casts,  etc.  It  is  impossible, 
however,  with  a  power  of  500,  to  focus  properly,  and 
very  difficult  even  with  lower  powers. 

If  the  urine  be  clear  it  is  often  necessary,  in  order  to 
obtain  sufficient  sediment  for  examination,  to  decant 
the  supernatant  liuid  several  times,  and  even  then,  in 
interstitial  nephritis  where  there  is  polyuria,  the  visible 
sediment  will  be  so  slight  that  the  examination  of  it  is 
facilitated  by  mixing  it  in  a  small  concave  dish  with  an 


74  bright' S   DISEASE. 

equal  part  of  glycerine,  and  allowing  the  watery  portion 
to  evaporate. 

When  the  urine  is  alkaline,  or  when  two  or  three 
days  are  required  to  prepare  the  urine  for  and  to  make 
the  examination,  about  one-tenth  part  of  a  one-half  per 
cent,  solution  of  chromic  acid  may  be  added  to  the  urine. 
This  will  keep  the  urine  from  decomposition  and  the 
formation  of  animal  and  vegetable  organisms  for  an 
indefinite  time. 


CHAPTER  XIII. 

NEPHRITIS. 

Although  most  of  the  conditions  I  shall  describe  would 
usually  be  designated  as  Bright' s  disease,  I  consider 
the  term  too  general  and  indetinite  to  apply  to  distinct 
and  definite  lesions  of  the  kidney.  In  an  analysis  which 
I  have  made  of  all  the  cases  described  by  Bright  in  his 
celebrated  "Reports  of  Medical  Cases,"  I  find  that  in 
nearly  every  case  albumin  was  found  to  be  present,  and 
so  far  as  I  know  the  term  Bright' s  disease  has  been 
applied  in  a  general  way  to  organic  changes  or  func- 
tional disturbances  of  the  kidney  characterized  by  the 
presence  of  albumin  in  the  urine.  That  nephritis  and 
even  cirrhosis  may  exist  without  albumin  is  shown  in 
Chapter  XIX. 

In  his  "  Reports  "  '  Bright  gives  the  details  of  thirty- 
one  cases  at  Guy's  Hospital  terminating  fatally,  in  which 
the  autopsies  showed  the  existence  of  organic  disease  of 
the  kidneys.  In  all  but  four  of  these  cases  the  nephritic 
lesions  were  evidently  the  direct  or  indirect  cause  of 
death.  The  four  cases  in  which  the  cause  of  death 
could  not  necessarily  be  sought  in  the  kidneys  were : 
1.  Malignant  ulcer  of  the  oesophagus:  kidney  lesion; 
two  cysts  in  cortical  portion.  2.  Chronic  diarrhoea : 
kidneys  had  undergone  a  kind  of  fatty  degeneration. 
3.  Fatal  chorea :  kidneys  whitish,  mottled,  and  rather 
large.  4.  Stupor  without  pressure  :  kidneys  slightly 
mottled.     In  these  four  cases  no  mention  is  made  of 

■  R.  Bright's  Report  of  Medical  Cases,  3  vols.     London,  1827. 


76  bkight's  disease. 

albumin  being  found  in  the  urine.  In  the  twenty- seven 
other  cases,  the  clinical  history  of  all  being  given,  the 
urine  was  found  to  be  coagulable  before  or  after  death 
in  twenty-four  cases.  In  the  remaining  cases  it  is  not 
mentioned  whether  the  urine  was  tested  for  albumin. 
In  addition  to  the  foregoing,  Bright  reports  three  cases 
of  anasarca  with  coagulable  urine,  as  cured.  With  the 
recognition  of  albuminous  urine  in  these  fatal  cases  of 
nej)liritis  and  its  existence  in  other  dropsical  conditions, 
it  was  natural  that  he  should  regard  this  morbid  excre- 
tion as  a  necessary  clinical  accompaniment  of  the  kid- 
neys affected  by  disease  as  he  describes  them,  viz.  : 
"Kidneys  large,  disorganized  throughout;"  "kidneys 
firm,  hard,  granulated;"  "scrofulous  pus  near  pel- 
vis;" "  kidneys  lobulated — the  whole  hard  and  firm  ; ' ' 
"kidneys  small,  hard,  and  almost  cartilaginous;" 
"kidneys  large,  dark,  and  of  a  chocolate  color,"  etc. 

Bright' s  observations  threw  a  flood  of  light  upon 
many  clinical  conditions,  the  causes  of  which  had  been 
unknown,  and,  considering  that  his  examinations  of  the 
kidney  were  made  without  the  aid  of  a  microscope,  his 
descriptions  of  their  conditions,  emerging  as  he  did 
from  almost  Cimmerian  darkness,  are  good,  though  in 
many  cases  short  and  insufiicient,  as  may  be  Judged 
from  some  of  the  preceding  descriptions.  His  macro- 
scopic illustrations  of  the  pathological  kidney  are,  how- 
ever, excellent,  and  modern  writers  on  nephritis  have 
not  hesitated  to  avail  themselves  of  the  beautiful  plates 
contained  in  his  celebrated  reports.  Even  Bright  him- 
self, however,  recognized  and  depicted  numerous  dis- 
similar conditions  of  the  kidneys,  and  although  several 
varieties  of  nephritis  were  shown  by  various  writers 
after  Bright,  notably  Rayer,  to  exist,  it  was  not  con- 
ceded until  a  lapse  of  twenty-five  years,  and  after  much 
discussion,  that  there  existed  forms  of  this  disease 
pathologically  distinct  and  different,  and  that  the  term 


NOMENCLATURE    OF   BRIGHT' S   DISEASE.  77 

Bright' s  disease  was  a  sweeping  appellation,  covering  a 
multiplicity  of  conditions  essentially  unlike. 

When  we  consider  that  microscopic,  and,  later,  patho- 
logical investigations,  have  revealed  such  a  variet}^  of 
changes  in  the  kidneys,  of  a  distinct  and  definite  char- 
acter, unknown  to  and  unrecognized  by  Bright,  I  be- 
lieve the  period  not  remote  when  the  nomenclature  of 
affections  of  the  kidneys  will  designate  simply  the 
character  of  the  pathological  changes,  as  fatty,  waxy 
degeneration,  interstitial  or  croupous  nephritis,  cir- 
rhosis, etc.  At  present,  certainly,  it  appears  from 
Bright's  own  writings  that  the  name  "  Bright' s  disease  " 
has  been  applied  to  those  diffuse  inflammations  of  the 
kidneys  accompanied  by  albuminous  urine,'  either  con- 
stant or  intermitting.  The  terse  descriptions  which 
Bright  generally  gave  are  insufficient,  though  with  the 
clinical  histories  they  are  of  great  interest. 

I  consider  that  all  forms  of  nephritis  may  be  com- 
prised in  three  varieties :  I.  Croupous.  II.  Intersti- 
tial.   III.  Suppurative. 

The  waxy  and  fatty  kidney  being  simply  an  inter- 
current or  subsequent  development  upon  one  of  the 
above  forms,  and  not  a  condition  independent  of  other 
lesions  of  the  kidney,  I  regard  the  two  first  not  as 
essentially  distinct  diseases  of  the  kidneys,  but  as 
identical  in  character  but  differing  in  the  degree  in 
which  the  connective  tissue  and  the  epithelia  are  re- 
spectively affected.  They  always,  as  will  be  shown, 
coexist,  and  one  cannot  exist  without  the  other  being 
developed  at  least  in  some  degree. "" 

'  From  a  paper  hj  the  author  in  tlie  New  York  Medical  Journal,  No- 
vember, 1882. 

- 1  find  myself  supported  in  this  view  by  Prof.  Eosenstein,  who  in  a  paper 
read  before  the  International  Medical  Congress  at  Amsterdam  in  1879,  con- 
cludes that — "  1.  The  anatomical  lesions  of  the  kidneys,  which  determine 
the  group  of  clinical  symptoms  first  described  by  Bright,  always  involve  the 


78  beight's  disease. 

All  inflammatory  conditions  of  the  kidney  arise,  as  a 
matter  of  course,  from  the  vascular  apparatus  of  the 
connective  tissue. 

parenchyma  as  well  as  the  connective  tissue  of  those  organs.  2.  There  is 
neither  an  exclusive  parenchymatous  nephritis  nor  an  exclusively  intersti- 
tial nephritis.  Experiment  and  clinical  observation  show  that  where  a  true 
diffuse  renal  inflammation  takes  place,  both  histological  elements  are  affected 
from  the  commencement.  3.  The  final  issue  of  diffuse  renal  inflammation 
is  the  white  kidney  and  red  granular  kidney.  They  form,  from  the  ana- 
tomical point  of  view,  the  atrophied  kidney,  and  only  differ  in  this,  that  the 
parenchymatous  lesion  is  more  pronounced  in  the  former,  the  interstitial 
affection  in  the  latter.  Clinically  the  two  may  be  distinguished  by  analysis 
of  the  urine.  The  symptoms  of  atrophy  are  common  to  both  modifications. 
4.  Clinical  observation  makes  it  very  probable  that,  just  like  the  white 
kidney,  the  red  granular  kidney — or,  as  it  is  now  called,  '  primary  cir- 
rhosis ' — is  preceded  by  periods  of  swelling,  and  this  is  not  contradicted  by 
pathological  research." 


CHAPTER  XIV. 

CROUPOUS   NEPHEITIS.— CHARACTERISTICS.— ACUTE   CROUPOUS 

NEPHRITIS. 

This  is  variously  known  as  tiibal  nepTiritis  ;  'parenchy- 
matous nepTiritis  ;  non  desquamative  nephritis,  in  ad- 
vanced stages  producing  the  '•''large  lohite  'kidney,''''  or 
"  atropliied  kidney.^'' 

I  consider  croupous  tlie  most  appropriate  name  for 
tlie  form  of  nephritis  I  shall  describe,  because  there  is 
diffuse  and  intense  exudation  or  infiltration  into  the 
connective  tissue  with  hypergemia,  albumin,  or  casts,  or 
a  fibrinous  exudate  into  the  tubuli  uriniferi.  These 
conditions  are  unvarying  features  of  the  disease.  The 
term  tubal  nephritis  designates  simply  a  lesion  of  the 
tubules,  while  this  is  never  exclusive,  an  exclusive  in- 
flammation of  any  portion  of  the  kidney,  as  the  epithe- 
lia,  connective  tissue,  or  glomerulus,  being  impossible. 
The  term  parenchymatous  is  equally  objectionable,  in- 
dicating as  it  does  the  essential  lesion  of  the  kidney  to 
be  in  the  epithelium. 

In  croupous  nephritis  there  is  diffuse  exudation  into 
the  tubuli  uriniferi  and  into  the  connective  tissue,  while 
in  interstitial  nephritis  there  is  always  more  or  less  stria- 
tion  of  the  connective  tissue  in  the  cortical  substance. 

Acute  Ceoupous  N'epheitis, 

Generally  known  as  "acute  Bright' s  disease,"  may 
therefore  be  defined  as :  Nephritis  characterized  hy 
exudation  into  and  infiltration  of  the  connective  tissue, 


80  bright' S  DISEASE. 

with  secondary  changes  in  the  epithelia,  the  whole 
leading  to  the  formation  of  casts  and  being  invariably 
accompanied  by  albuminous  urine. 

It  is  superfluous  to  make  separate  classifications  of 
acute  croupous  nephritis  according  to  the  etiology  of 
the  case,  as  for  example,  to  make  scarlatinous  nephritis 
a  form  of  nephritis  sui  generis,  as  it  does  not  necessa- 
rily show  any  different  lesions  from  the  nephritis  of 
cold,  diphtheria,  etc.  Nor  is  the  term  glomerulo-ne- 
phritis  properly  used  as  designating  a  distinct  disease, 
since  contrary  to  the  assertion  of  Klebs,  it  may  be 
shown  that  other  lesions  than  inflammation  of  the  glo- 
merulus always  exist  in  acute  croupous  nephritis ;  the 
glomerulus  is  always  affected. 

Etiology. 

The  causes  of  acute  croupous  nephritis  are  numerous  ; 
the  most  common,  according  to  my  own  observations, 
being,  in  the  order  named,  "taking  cold,"  the  influ- 
ence of  damp  cold,  scarlatina,  diphtheria,  malarial  poi- 
soning producing  severe  bilious  remittent  fever  or  fever 
and  ague ;  after  these  come  those  cases  (which  are, 
however,  rare)  produced  by  the  direct  effect  of  sub- 
stances which  act  upon  the  kidney  as  irritant  poisons, 
such  as  turpentine,  the  bichloride  of  mercury,  ginger, 
cantharides,  arsenic,  etc. 

The  influences  of  the  above  causes  are  well  known  if 
I  except  the  effects  of  ginger  and  of  malarial  poisoning. 

I  am  not  aware  that  ginger  has  been  mentioned  as 
capable  of  producing  renal  inflammation.  The  follow- 
ing case,  however,  shows  that  it  may  produce  nephritis 
of  a  severe  character  ;  it  occurred  in  my  practice  sev- 
eral years  ago. 

The  patient  was  a  gentleman,  thirty-four  years  of  age, 
whose  health  was  excellent  except  that  he  was  a  suf- 


ACUTE   CKOUPOUS   NEPHRITIS — ETIOLOGY.  81 

ferer  from  dyspepsia,  producing  severe  flatulent  colic. 
To  obtain  relief  from  this  lie  one  day  took,  at  intervals 
of  an  hour,  a  teaspoonful  of  Brown's  essence  of  ginger. 
The  next  morning  at  5  o'clock  he  had  a  severe  chill 
with  incessant  micturition  and  strangury.  It  was  as  if 
he  had  taken  a  strong  injection  of  nitrate  of  silver. 
There  was  considerable  fever  ;  urine  scanty,  highly  al- 
buminous, and  containing  blood.  To  relieve  the  scald- 
ing and  pain  I  prescribed  a  mixture  of  hyoscyamus 
and  bicarbonate  of  potash,  which  was  taken  in  alter- 
nation with  aconite.  In  two  days  the  patient  was 
quite  well.  I  had  attributed  the  attack  to  sudden 
cold,  but  was  surprised  by  the  rapid  cure.  A  week 
after,  he  took  the  ginger  in  similar  doses ;  it  was  fol- 
lowed by  the  same  effects.  This  time  I  discovered  the 
cause  of  the  attack.  He  discontinued  the  use  of  the  drug, 
and  has  had  no  trouble  with  the  kidneys  since.  The  ef- 
fect was  precisely  analogous  to  that  of  cantharides  in 
doses  which  are  not  poisonous,  as  shown  by  Cornil,  who 
states  that  the  cells  in  the  urinif erous  tubules  quickly 
return  to  their  normal  state,  though  hyaline  casts  are 
found  in  their  interior  twenty  or  thirty  hours  after.  The 
congestion  excited  by  the  irritants  above  mentioned 
is  generally  evanescent,  leaving  no  permanent  change. 
Short  as  was  the  duration  of  the  attacks  produced  by 
the  ginger,  they  were  typical  cases  of  acute  nephritis. 

Bouchard  recognizes  an  ^^  infect  ions  "  nephritis,  either 
transient  or  permanent,  caused  by  infectious  elements 
in  the  blood,  which  in  the  course  of  their  elimination  by 
the  kidney  irritate  the  organ  in  their  passage  and  alter 
its  structure.  This  nephritis  is  often  produced  in  scar- 
latina, diphtheria,  typhoid  fever,  pneumonia,  small-pox, 
etc.  He  has  also  shown  that  in  these  conditions  microbes 
traverse  the  kidney,  producing  irritation,  congestion, 
albuminuria,  etc.,  these  disappearing  as  the  fever  di- 
minishes and  disappears. 
6 


82  beight's  disease. 

Capitan  has  produced,  in  a  number  of  instances,  ne- 
phritis with  hematuria  by  intra-venous  injections  of  beer- 
yeast,  the  spores  in  24  hours  appearing  in  the  blood  and 
urine,  with  albuminuria  casts,  etc.  The  nephritis,  spores, 
etc.,  disappeared  in  a  few  days. 

The  theory  of  so  distinguished  an  investigator  as  Pro- 
fessor Semnola,  of  Naples,  deserves  mention,  though  it 
does  not  seem  possible  to  me  that  the  causology  of  more 
than  a  limited  proportion  of  cases,  if  any,  of  nephritis 
is  what  he  claims  it  to  be.  Briefly  he  finds  that  the  in- 
jection or  transfusion  of  various  kinds  of  albumin  into 
the  blood  of  animals  produces  albuminuria  and  ne- 
phritis. He  states  that  in  Bright' s  disease  there  is  a 
general  transudation  of  albumin,  it  being  found  in  the 
bile,  saliva,  etc.  He  finds  ordinary  egg  albumin  most 
liable  to  transude  and  cause  irritative  trouble.  He  be- 
lieves the  cause  of  renal  albuminuria  to  be  found  in  the 
blood.  These  two  points  must,  however,  be  borne  in 
mind:  1st.  There  are  numerous  substances  which  in- 
jected into  the  blood  will  produce  albuminuria.  2d. 
Albumin  in  the  secretions  is  not  necessarily  an  indica- 
tion that  albumin  in  the  blood  causes  nephritis  ;  it  may 
be  the  result  of  the  latter.  The  only  practical  deduc- 
tion from  his  experiments,  however,  seems,  in  the  opin- 
ion of  the  Medical  Mecord,  ' '  that  egg  albumin  should 
be  forbidden,  and  serum  albumin  prescribed  as  an  arti- 
cle of  diet." 

The  possibility  of  malarial  poisoning  producing 
acute  nephritis  has  been  questioned.  It  is,  I  think,  a 
very  infrequent  cause.  Still  I  have  known  several  in- 
stances where  it  has  been  thus  produced.  Two  especially 
illustrative  are  the  following  : 

Case  I. — Mr.  F ,  aged  forty-two.  In  tlie  summer  of  1876  lie  suf- 
fered, wliile  in  the  country,  with  severe  fever  and  ague.  Returned  to 
town  in  October  and  considered  himself  cured.  During  the  middle  of 
the  month,  however,  the  quotidian  type  of  intermittent  fever  declared 


ACUTE   CEOUPOUS   NEPHRITIS — ETIOLOGY,  83 

itself.  The  paroxysms  were  severe,  accompanied  by  great  bilious  de- 
rangement, white  tongue,  and  violent  vomiting.  In  about  a  week 
they  were  broken  up,  but  a  few  days  after  the  urine  became  scanty, 
the  face  swollen,  and  nausea  reappeared.  On  examining  the  urine  I 
found  blood,  albumin,  epithelia,  and  blood  casts.  The  attack  proved 
a  severe  one,  and  it  was  several  weeks  before  convalescence  was  estab- 
lished.    Mr.  F 's  health  had  been  for  many  years  exceptionally 

good  previous  to  the  attacks  of  malarial  fever.  Fuller  details  are 
given  under  Case  V. 

Case  II. — Acute  Hemorrhagic  Nephritis  accompanying  Malignant  Re- 
mittent Fever. — This  case  occuiTed  in  a  locality  of  North  Carolina, 
where  it  is  frequent  and  almost  always  fatal.  It  is  known  there  as 
"black  jaundice."  The  urine  of  a  patient  thus  affected  was  sent  to 
New  York  in  the  autumn  of  1882,  and  examined  by  me  with  the  follow- 
ing results : 

1,  Urine  dark,  like  molasses;  2,  highly  albuminous;  3,  epithelia 
from  pelvis  of  kidney ;  4,  blood  ;  5,  pus  corpuscles ;  6,  epithelia  from 
convoluted  tubules ;  7,  epithelial,  granular,  and  blood  casts  ;  8,  shreds 
of  connective  tissue ;  9,  coagulated  blood  plasma. 

Diagnosis  :  Acute  TiemorrTiagic  nephritis  with  pye- 
litis, ulceration,  and  septiccBmia.  I  ham  made  draw- 
ings of  all  the  abom-named  elements. 

The  Symptoms 

Are  often  numerous,  and  vary  greatly  according  to  the 
degree  of  inflammation.  After  scarlatina,  diphtheria, 
or  sudden  taking  cold,  but  particularly  after  the  two 
former  causes,  there  may  be  complete  anuria,  this 
condition  being  accompanied  or  rapidly  followed  by 
dropsy,  anasarca  of  the  lungs,  hydrothorax  dropsy  of 
the  pericardium  or  of  the  extremities.  In  milder  cases 
there  will  be  frequent  micturition,  small  quantities  of 
urine  being  passed.  As  a  rule  the  quantity  of  the  urine 
is  greatly  diminished.     Charcot*  gives  of   this  the  fol- 

'  Briglit's  Disease. 


84  bkight's  disease. 

lowing  explanation,  which  the  reader  can  adopt  or  re- 
ject : 

"This  scantiness  of  the  urine  is,  moreover,  explained 
by  the  dropsy  which  is  here  an  habitual  phenomenon  ; 
by  the  anaemia  of  the  cortical  substance  of  the  kidney, 
which  is  not  in  this  order  of  facts  the  occasion  of  a  work 
of  compensation  on  the  part  of  the  heart ;  perhaps,  also, 
by  the  abundance  of  urinary  casts,  which,  in  certain 
cases  at  least,  may  act  as  tubular  infarctions  and  hin- 
der secretion.'- 

The  specific  gravity  is  usually  high,  the  urine  gener- 
ally acid ;  the  amount  of  urea  is  greatly  diminished, 
while  that  of  the  uric  acid  is  not  materially  altered. 

Albumin  is  invariably  present,  and  usually  in  large 
proportions.  In  children  the  heart  often  becomes  rap- 
idly enlarged.  Nausea  often  exists  and  persistent  head- 
aches. Convulsions  occur  from  ursemic  poisonings  ;  there 
is  sometimes  oedema  of  the  larynx,  and  occasionally, 
but  very  seldom,  epistaxis.  Ursemic  symptoms  are  much 
less  common  than  in  interstitial  nephritis,  while  affec- 
tions of  the  retina  are  seldom  met  with.  The  tempera- 
ture is  often  somewhat  elevated,  but  does  not  attain  a 
high  degree. 

A  microscopic  examination  of  the  urine  shows  epi- 
thelial, blood,  or  granular  casts,  or  all  of  these,  with 
perhaps  a  few  hyaline  casts,  pus  corpuscles  and  epithelia 
from  the  convoluted  tubules,  and  perhaps  from  the 
straight  tubules.  In  case  the  inflammation  be  of  a  se- 
vere character,  more  or  less  blood  corpuscles  will  be 
found.  If  the  pelvis  be  affected,  which  is  generally  the 
case,  epithelia  from  the  pelvis  of  the  kidney  will  often 
be  found,  showing  the  existence  of  pelvilitis. 

The  casts  in  severe  forms  of  acute  croupous  nephritis 
are  very  numerous,  and  are  found  in  such  abundance  in 
no  other  condition. 


ACUTE   CROUPOUS   NEPHRITIS.  85 


Diagnosis. 

Acute  croupous  nephritis  may  easily  be  recognized  by 
the  diminution  and  high  specific  gravity  of  the  urine, 
by  the  considerable  quantity  of  albumin,  by  the  absence 
of  greatly  increased  impulse  of  the  heart,  by  the  nausea, 
dropsy  or  anasarca,  by  the  absence  of  epistaxis,  but 
most  of  all  by  the  existence  of  epithelial  and  granular 
casts,  neither  of  which  are  ever  found  in  interstitial 
nephritis. 

Course  and  Prognosis. 

While  acute  croupous  nephritis  may  rapidly  lead  to 
a  fatal  termination,  and  although  the  symptoms  and 
appearances  of  the  patient  seem  more  appalling  than 
those  which  usually  accompany  chronic  interstitial  ne- 
phritis, it  is  consolatory  to  know  that  the  prognosis  as  re- 
gards recovery  is,  with  proper  treatment,  almost  always 
favorable.  IS'ot  only  is  this  the  case,  but  the  cure,  if 
effected,  is  radical.  I  have  never  yet  known  of  an 
instance  of  chronic  interstitial  or  croupous  nephritis, 
where  proper  treatment  and  care  had  been  employed,  to 
result  from  an  attack  of  acute  croupous  nephritis. 

As  regards  the  duration  of  this  form  of  nephritis,  of 
course  it  must  be  very  variable.  I  have  known  com- 
plete restoration  to  health  to  be  brought  about  in  three 
or  four  weeks,  while  in  other  cases  two  or  three  months 
have  been  necessary  to  bring  about  complete  absence 
from  the  urine  of  casts,  epithelia,  albumin,  and  the 
other  indications  of  nephritis. 

Treatment. 

As  all  the  general  principles  of  treatment,  as  well  as 
the  specific  measures  suitable  to  each  particular  form  of 
nephritis,  are  applicable   to  all  the  principal  forms  of 


86'  bkight's  disease. 

nepliritis  which  I  shall  describe,  namely,  acute  and 
chronic,  croupous  and  interstitial  nephritis,  I  will  treat 
of  this  part  of  the  subject  after  the  characteristics  of 
each  form  have  been  considered,  believing  that  the  mat- 
ter of  therapeutics  will  thus  be  better  understood. 

Pathology. 
Macroscopic  Appearances  of  the  Kidney. 

The  kidneys  are  always  enlarged,  the  cortical  sub- 
stance thickened,  and  the  whole  organ  usually  very  vas- 
cular and  dripping  with  blood.  The  capsule  is  not 
adherent,  the  surface  is  smooth  and  glistening  and  is 
generally  mottled,  and  occasionally  there  will  be  white 
patches  ;  the  vessels  are  often  marked  and  have  a  turgid 
appearance  or  present  a  fine  capillary  network.  IS'either 
the  granular  aj)pearance  nor  indentations  found  in  in- 
terstitial nephritis  occur,  nor  the  white  variegated  ap- 
pearance of  the  large  white  kidney  of  parenchymatous 
nephritis,  nor  the  uneven  lobulated  appearance  of  the 
atrophied  kidney.  Irregular  cicatricial  contractions  are, 
however,  often  found.  The  Malpighian  bodies  appear 
distinctly  to  the  eye  as  red  dots. 

The  whole  kidney  is  soft,  unresisting  to  the  knife,  and 
appears  of  a  dark  brown  or  chocolate  color.  The  en- 
largement of  the  kidney  is  always  considerable,  some- 
times very  great.  I  found  the  kidneys  of  a  child  four 
years  old,  who  died  from  this  form  of  nephritis  following 
diphtheria,  to  weigh  4  ozs.  each.  IS'umerous  instances 
are  recorded  where  each  kidney,  in  the  adult  subject, 
weighed  from  Q^  to  11  ozs. 

Microscopical  Appearances,  and  Phenomena  of  the 
Inflammation. 

In  examining  sections  of  the  kidney  affected  by  acute 
croupous  nephritis  we  are  sure  to  find  numerous  changes 


ACUTE  CROUPOUS  NEPHRITIS. 


87 


in  the  epithelia  and  the  glomeruli,  together  with  casts 
in  the  tubules.  If  the  nephritis  have  been  of  a  severe 
form,  the  connective  tissue  will  be  found  interspersed 
with  medullary  or  inflammatory  corpuscles. 

The  intra-tubular  changes  are  as  follows :  In  mild 
cases  the  epithelia  appear  enlarged  and  bulky  (consti- 
tuting what  is  generally  known  as  cloudy  swelling). 


Fig.  14. — Acute  Croupotts  Nephritis. — A,  swelled  and  coarsely  granular  epithelia; 
cross-sections  of  convoluted  tubules;  B,  broken-down  or  attenuated  epithelia;  C,  structureless 
membrane ;  D,  connective  tissue  interspersed  with  inflammatory  corpuscles.  (Magnified  600 
diameters.) 


The  swelling  of  the  epithelia  is  often  so  great  as  to 
cause  them  to  approximate  each  other,  and  even  to  close 
the  lumen  of  the  tubule.  The  epithelia  of  the  tubules 
of  the  cortex  are  mostly  affected  ;  those  of  the  straight 
tubules  less  so.  The  increased  bulk  of  the  epithelia  is 
clearly  due  to  the  increase  of  the  living  matter  consti- 
tuting the  reticular  structure  of  all  the  epithelia,  par- 
ticularly the  rod-like  structure.  This  rod-like  structure 
is  very  clearly  defined  in  croupous  and  in  acute  catarrhal 
nephritis.  It  can  be  recognized  by  comparatively  low 
powers  (500),  but  is  best  seen  by  preparing  the  specimen 


88 


BEIGHT'S   DISEASE. 


in  the  chloride  of  gold  solution,  as  described  in  Chapter 
II. 

The  affected  epithelia  become  of  a  dark  violet  color  ; 
in  the  healthy  kidney  this  coloration  is  not  produced, 
a  dark-brownish  coloration  being  the  result. 


Fig.  15. — Convoluted  Tubule  from  a  Human  Kidney  affected  with  Acute  Ca- 
TARRHAi,  (Interstitial)  Nephritis.  (Oblique  section — magnified  1,200  diameters.) — P,  in- 
flammatorj'  corpuscle,  sprung  from  the  division  of  an  epithelium  ;  D,  cluster  of  inflammatory 
corpuscles,  sprung  in  the  same  manner ;  R,  rods  of  ciiboidal  epithelia,  still  recognizable ;  E, 
endothelia,  increased  in  size  and  number. 

The  new  formation,  in  nephritis,  of  corpuscular  ele- 
ments starts  at  the  points  of  intersection  of  the  retic- 
ulum. This  so-called  endogenous  uqw  formation  of 
living  matter  is  especially  plain  in  the  inflammatory 
process  invading  epithelial  formations.  Here  it  is  im- 
portant to  note  the  reticulum  first  becomes  coarse,  next 
it  coalesces  into  lumps,  which  at  first  being  homogene- 
ous in  turn  assume  a  reticular  structure  themselves,  and 
now  represent  so-called  inflammatorj^  or  pus  corpuscles. 

In  croupous  as  well  as  in  interstitial  nephritis  the 
rods  of  the  epithelia  throughout  the  tubules  are  clumsy 


ACUTE   CKOUPOUS   NEPHEITIS.  89 

and  bulky,  the  whole  reticulum  being  enlarged,  render- 
ing the  epithelium,  with  low  powers  of  the  microscope, 
coarsely  granular.  In  many  instances  the  rods  are  not 
discernible,  as  in  their  place  a  coarsely  granular  mass 
is  present,  pervading  the  whole  epithelial  body,  or  else 
the  innermost  portion  of  the  epithelium  looks  coarsely 
granular,  the  outermost  portion,  on  the  contrary,  being 
homogeneous  and  shining.     (Chapter  II.) 

I  have  thus  far  found  the  rods  in  this  form  of  ne- 
phritis plainly  discernible  only  in  the  ascending  tubules. 
The  coarsely  granular  appearance  of  the  epithelia  is 
always  present  in  a  greater  or  less  degree  in  acute 
croupous  nephritis. 

Many  tubules  will  be  found  filled  up  by  the  enor- 
mously swelled  epithelia  (Fig.  16,  E) ;  in  others  by  a 
mass  of  detached  epithelia  presenting  an  appearance 
nearly  normal,  and  others  with  broken-down  and  dis- 
integrated epithelia,  or  with  albuminous  exudation  and 
indifferent  amorphous  bodies,  broken-down  epithelia, 
and  granular  matter. 

Some  epithelia  will  be  found  still  preserving  their 
nuclei,  the  remaining  part  wasted,  translucent,  and 
thin,  showing  fine  granulations,  or  these  being  absent, 
presenting  the  appearance  of  a  structureless  membrane. 

In  some  cases  the  transition  from  the  epithelial  struc- 
ture to  inflammatory  and  pus  corpuscles  can  be  clearly 
traced.  The  nuclei  of  the  epithelia  will  be  found  to  be 
replaced  by  inflammatory  or  pus  corpuscles,  in  some 
tubules  the  epithelia  being  quite  or  nearly  gone,  and 
the  tubule  being  filled  with  inflammatory  and  pus  cor- 
puscles. 

This  is  shown  by  Fig.  16,  p.  90. 

The  connective  tissue  about  the  tubules  is  somewhat 
thickened,  and  when  the  specimen  is  colored  by  car- 
mine presents  a  waxy  appearance,  which  is,  however, 
due  to  the  albuminous  exudation.    The  epithelia  do  not 


90 


beight's  disease. 


readily  take  up  the  carmine  stain,  but  remain  brown. 
The  connective  tissue  assumes  the  carmine  tint.  The 
interconnective  tissue  is  found  to  have  an  albuminous 
appearance  and  to  contain  numerous  inflammatory  cor- 
puscles. 

The  intertubular  spaces  are  many  of  them  widened  by 
the  exudation.     In  acute  hemorrhagic  nephritis  some 


Fig.  16. — Suppubative  Nephbitis. — A,  Epithelia  and  masses  of  living  matter,  some  homo- 
geneous and  some  having  differentiated  into  inflammatory  corpuscles ;  B,  pus  corpuscles ; 
C,  shining  lumps  of  matter,  epithelium  dividing  ;  D,  shining  lumps  of  matter  and  inflamma- 
tory corpuscles ;  E,  tubule,  with  granular  matter  greatly  enlarged  and  epithelia  enormously 
swollen ;  F,  tubules,  with  endothelia  and  broken-down  epithelia  and  granular  matter ;  Gr, 
tubule  filled  with  pus  corpuscles ;  H,  epithelia,  the  nuclei,  and  granular  matter  undergoing 
transformation  into  shining  lumps ;  I,  thickened  connective  tissue.  (Transverse  section  mag- 
nified 500  diameters.) 

of  the  tubules  will  be  filled  with  blood.  An  interesting 
and  important  feature,  as  showing  the  nature  and  for- 
mation of  casts,  is  the  part  that  occasionally  tubules 
and  epithelia  will  be  found  containing  droplets  of  an 
albuminous  exudate,  some  free  in  the  tubules  and  some 
interspersed  throughout  the  epithelia.  The  epithelia 
evidently  enters  into  the  formation  of  the  cast  and  per- 
ishes in  the  transformation. 


ACUTE  CROUPOUS  NEPHRITIS.  91 

These  changes  are  shown  by  Fig.  11,  A. 

This  case  is  of  interest,  as  there  is  as  yet  no  cast 
formed  and  the  epithelia  are  not  sufficiently  destroyed 
to  have  been  replaced  by  endothelia.  The  various 
changes  of  the  epithelia  are  well  shown  in  this  figure 
from  the  cloudy  swelling,  which  is  very  great,  the  gran- 
ular matter,  the  emaciated,  as  it  were,  epithelia,  and  the 
large  and  small  droplets.  The  kidney  showed  numer- 
ous fully  formed  casts  all  surrounded  by  endothelia. 

The  Malpighian  tuft  undergoes  numerous  changes, 
the  most  common  of  which  are  that  the  blood-vessels 
are  sometimes  enormously  swollen,  always  dilated,  and 
usually  covered  with  inflammatory  corpuscles.  Some- 
times the  capsule  and  interstices  of  the  tuft  will  be 
filled  with  albumin. 

Fatty  casts  and  fatty  degeneration  in  purely  acute 
croupous  nephritis  do  not  usually  occur.  Hemorrhagic 
infarctions  are  not  uncommon.  Casts  are  numerous, 
the  hyaline  being  most  frequently  met  with  in  this  form 
of  nephritis,  although  epithelial  and  blood  casts  are 
common ;  granular  casts  are  rarer.  The  casts  may  be 
seen  in  transverse  and  longitudinal  sections,  and  are 
seldom  surrounded  by  endothelia,  as  in  chronic  nephri- 
tis. The  granular  and  hyaline  casts  readily  take  the 
carmine  stain. 


CHAPTER  XV. 

CHRONIC  CROUPOUS  NEPHRITIS. 

It  is  this  form  of  nephritis,  also  known  as  tubal,  paren- 
chymatous, or  non-desquamative  nephritis,  which  leads 
to  the  form  of  kidney  known  as  the  '''■  atrophied  Mdney,''' 
' '  contracted  Mdney, ' '  ' ''fatty  liidney, ' '  the  "  large  white 
Tcidney^^''  '•'■  BrighVs  Jcidney,''''  ''''large  smooth  Mdney,"' 
the  ^'' large  mottled  Mdney,''''  the  '•''fatty  granular  Md- 
ney,'''' and  '"'■  small  fatty  Mdney, ^''  all  these  conditions 
being  produced  by  the  inflammation  in  the  kidney  and 
all  the  above  designations  being  employed. 

Etiology. 

Chronic  croupous  nephritis  sometimes,  though  sel- 
dom, is  the  result  of  acute  croupous  nephritis.  It  is 
doubtful  if  ever  it  arises  from  the  acute  nephritis  of 
scarlatina.  In  the  very  rare  cases  where  it  has  been 
shown  to  originate  in  acute  croupous  nephritis,  the  latter 
has  always  been  the  result  of  some  violent  action,  cold 
upon  the  skin  or  "taking  cold."  Charcot'  says,  relative 
to  this  point :  "  It  is  true  that  permanent  parenchymat- 
ous nephritis  sometimes  commences  like  an  acute  dis- 
ease, that  is  to  say,  suddenly,  with  the  accompaniment 
of  febrile  action  more  or  less  pronounced,  and  more  or 
less  lasting.  But  we  must  recognize  the  fact  that  these 
instances  are  not  numerous  ;  they  seem  to  be  met  with 
oftener  in  England  than  almost  anywhere  else.     Thus, 


'  Bright's  Disease,  Millard's  translation,  p.  77. 


CHROlSriC    CROUPOUS   NEPHRITIS — ETIOLOGY.  93 

Bai'tels  says  that  in  England  lie  saw  but  one  case  of 
this  kind  ;  Wilks,  on  the  other  hand,  has  collected  four 
or  five  ;  Dickinson  nearly  as  many ;  Bright  has  cited 
three  that  came  under  his  observation  ;  I  do  not  think 
there  are  many  reported  in  French  publications. 

' '  All  these  cases  seem  to  have  the  peculiarity  in  com- 
mon of  being  contracted  under  the  influence  of  cold, 
the  body  being  in  a  perspiration.  For  example,  in  a 
case  observed  by  Wilks  (Bright' s  Disease,  'Gruy's  Hos- 
pital Reports,'  1852)  a  man,  twenty-eight  years  of  age, 
being  heated  and  in  a  state  of  intoxication,  threw  him- 
self into  the  Thames  and  swam  for  some  time ;  the 
next  day  there  was  considerable  anasarca  and  intense 
fever  ;  the  urine  was  scanty  and  dark  and  highly  albu- 
minous. The  patient  succumbed  at  the  end  of  three 
months,  in  consequence  of  a  gangrenous  inflammation 
of  the  skin  of  the  legs  and  scrotum,  consecutive  to 
punctures  made  for  the  purpose  of  evacuating  the 
liquid  of  the  oedema.  At  the  autopsy  the  kidneys  were 
found  to  be  greatly  enlarged,  and  to  present  already 
the  characters  of  the  large  white  kidney.  All  the  ob- 
servations of  acute  parenchymatous  Bright' s  disease 
having  an  acute  beginning  seem  made  upon  cases  nearly 
identical." 

I  have  known  a  few  instances  where  chronic  croup- 
ous nephritis  seemed  to  have  originated  in  an  acute 
attack,  but  they  have  been  rare,  and  the  acute  attack 
was  in  each  instance  caused  by  taking  cold.  I  am  con- 
strained to  believe,  however,  that  if  the  acute  nephri- 
tis be  imperfectly  cured,  although  the  symptoms  of 
nephritis  may  be  wanting  for  a  long  time,  sooner  or 
later  manifestations  of  chronic  croupous  nephritis  may 
occur. 

In  very  many  cases  the  etiology  is  unknown. 

It  is,  in  the  vast  majority  of  cases,  primarily  chronic 
or  subacute.     Its  causology  appears  to  be  the  same  as 


94  bright' S   DISEASE. 

that  of  many  cases  of  chronic  interstitial  nephritis.  The 
most  prominent  of  these  causes  are  undoubtedly  atmos- 
pheric conditions,  damp,  cold,  unfavorable  climate, 
check  of  perspiration,  etc. 

In  temperate  regions,  damp,  cold,  and  sudden  checks 
of  perspiration  are  probably  the  most  frequent  causes 
of  the  origin  of  this  form  of  nephritis.  According  to 
Bartels,  one  of  the  most  common  causes  of  this  condi- 
tion is  some  suppurative  process ;  it  is  a  frequent  ac- 
companiment of  inveterate  syphilitic  disease,  of  suppu- 
rative affections  of  the  joints,  and  of  tubercular  phthisis, 
and  Bartels  expresses  his  belief  that  some  noxious  ele- 
ment unknown  is  formed,  which  is  carried  by  the  blood 
into  the  kidneys,  producing  the  inflammation.  He  re- 
gards chronic  suppuration  as  the  most  common  cause  of 
croupous  nephritis.    This  is,  however,  erroneous. 

Next  to  that  he  places  malarious  poisoning,  adducing 
many  instances  where  it  seemed  caused  by  fever  and 
ague,  and  where  it  was  cured  at  the  same  time  with  it. 

I  have  met  with  a  few  cases  which  I  considered  as 
having  been  developed  by  repeated  attacks  of  intermit- 
tent fever.  Excess  in  alcoholic  beverages  and  mercury 
have  long  been  regarded  as  important  causes  of  paren- 
chymatous nephritis.  It  has  not  been  satisfactorily 
shown  that  either  of  the  above  is,  per  se,  an  important 
factor  in  its  production. 

There  is  no  doubt,  however,  that  structural  changes  of 
the  kidney  assuming  this  form  of  nephritis  may  occur  as 
a  secondary  result  of  the  inordinate  use  of  alcohol,  but 
when  they  are  so  induced,  I  believe  them  to  be  second- 
ary to  changes  in  other  parts  of  the  system,  especially 
of  the  liver.  Bartels'  experience,  indeed,  was  to  the  ef- 
fect that  organic  affections  of  the  kidney  were  less  nu- 
merous among  dram-drinkers. 

Charcot  states  that  neither  direct  irritants— as  can- 
tharides    or  turpentine — nor  diphtheria  nor  erysipelas 


CHROI!fIC   CROUPOUS   NEPHRITIS — ETIOLOGY.  95 

have  ever  been  positively  shown  to  have  produced  a  case 
of  this  disease. 

When  following  an  attack  of  acute  nephritis  it  will 
scarcely  escape  observation,  the  malady  being  then  sim- 
ply a  prolongation,  though  in  a  different  form,  of  the 
primary  one. 

Its  development  is  usually  very  slow.  Syphilis, 
scrofula,  and  phthisis  are  sometimes  accompanied  by 
and  seem  to  produce  it.  Undoubtedly  organic  or  severe 
functional  disorders  of  the  liver  may  induce  functional, 
and  eventually  structural,  kidney  changes.  Murchison ' 
states  that  his  experience  has  led  him  to  regard  lithae- 
mia  as  one  of  the  fruitful  causes  of  acute  nephritis  ;  also 
that  functional  derangements  of  the  liver,  resulting  in 
litheemia,  is  a  common  cause  of  the  contracted  granular 
or  gouty  kidney.  We  may,  however,  conclude,  from 
theory  and  experience,  that  the  above-mentioned  condi- 
tions need  not  necessarily  develop  the  interstitial  form 
of  nephritis,  but  may  sometimes,  as  there  is  evidence, 
produce  the  chronic  croupous  form.  Hepatic  disor- 
ders of  a  character  to  obstruct  the  portal  circulation  and 
to  embarrass  the  free  return  of  blood  from  the  renal 
veins,  as  in  cirrhosis,  fatty  liver,  enlarged  liver,  or 
chronic  hepatitis,  might  affect  the  renal  circulation  in 
such  a  manner  as  to  produce  nephritis,  while  in  other 
cases  the  lithic  acid  diathesis,  as  well  as  the  elements  re- 
tained in  the  blood  from  obstructed  action  of  the  liver, 
might  vitiate  the  blood  so  as  to  produce  renal  inflamma- 
tion. Indeed,  it  has  been  maintained,  though  without 
sufficient  reason,  that  chronic  nephritis  is  always  due 
to  a  morbid  condition  of  the  blood.  Johnson  ^  says  : 
"  Bright' s  disease  is  not  merely  a  local  malady  but  a 
disease  of  constitutional  origin,  and  the  proximate  cause 


'Functional  Derangements  of  the  Liver,  p.  78.    London,  1874. 
-Lectures  on  BrigM's  Disease,  American  Ed.,  p.  18. 


96  bright' S   DISEASE. 

of  the  renal  disease  is,  in  all  probability,  a  morbid  con- 
dition of  the  blood." 

This  is  sometimes  true,  and  admitting  this  we  may 
admit  that  vitiated  conditions  of  the  blood  which  some- 
times exist  with  hepatic  disorders  may  induce  renal 
inflammation.  Diphtheria  and  scarlatina  certainly  are 
accompanied  by  a  condition  of  the  blood  which  may 
produce  nepliritis. 

Heeeditary  Influence  as  a  Cause  of  Chronic 
Croupous  Nephrhcis. 

That  the  tendency  to  nephritis  may  be,  though  it 
rarely  is,  inherited,  has  been  clearly  shown  by  Dickin- 
son, Tyson,  and  others.  A  careful  examination  of  the 
inherited  cases,  however,  which  they  report  lead  me  to 
think  that  all  of  them  were  cases  of  interstitial  ne- 
phritis. I  have  thus  far  not  seen  any  undoubted  cases 
reported  of  inherited  croupous  nephritis. 

Age  when  Chronic  Croupous  I^ephritis  Most 
Frequently  Occurs. 

As  chronic  interstitial  nephritis  is  a  disease  of  middle 
and  advanced  age,  so  is  chronic  croupous  nephritis  a  dis- 
ease of  early  life.  It  is,  I  think,  most  likely  to  occur 
between  the  ages  of  twenty  and  thirty.  Its  tendency 
diminishes  after  the  latter  year.  This,  at  all  events, 
has  been  observed  in  my  own  experience,  and  it  has 
been  confirmed  by  the  statistics  of  Dickinson  and 
others. 

Pregnancy  as  a  Cause  of  Nephritis. 

Because  albumin  occurs  in  pregnant  women,  it  does 
not  follow  that  it  is  always  caused  by  pregnancy. 
AVomen,  pregnant  or  not,  are  liable  to  nephritis,  and 


CHKONIC   CROUPOUS   NEPHRITIS — ETIOLOGY.  97 

it  may  not  be  discovered  till  pregnancy  leads  to  a  urin- 
ary examination.  Nevertheless,  pregnancy  is,  I  believe, 
sometimes  the  cause  of  nephritis. 

This  theory  is  supported  to  a  considerable  extent  by 
the  fact  that  autopsies  show,  in  the  majority  of  cases,  a 
condition  of  intense  hypersemia  similar  to  that  v^hich  is 
produced  by  cardiac  obstruction  ;  in  the  first  stage  the 
kidneys  are  enlarged  beyond  theii'  natural  size,  and  in 
advanced  stages  become  contracted.  This  contracted 
kidney  is  due  to  one  of  two  causes :  1st,  to  a  primary 
inflammation  of  the  connective  tissue,  or,  2d,  what  is  more 
commonly  the  case,  according  to  Dickinson,  supported 
by  Braun,  who  gives  the  results  of  twelve  autopsies  after 
death  from  puerperal  convulsions,  it  is  what  is  known 
as  the  cyanotic  kidney,  the  contraction  and  induration 
being  perhaps  due  to  inflammation  resulting  from  ve- 
nous stasis,  produced  by  impeded  return  of  blood  from 
the  renal  veins. 

The  so-called  cyanotic  kidney,  however,  is  always  the 
result  of  inflammation,  and  the  twelve  cases  which 
Braun  describes  are,  from  his  description,  clearly  cases 
of  chronic  croupous  nephritis.  "Braun  states  that  in 
Vienna  44  cases  of  eclampsia  occurred  in  24,000  confine- 
ments. If  now  we  assume  that  nephritis  was  the  cause 
of  the  eclampsia  in  all  these  cases,  and  further  admit 
Rosenstein's  conclusion  that  in  one-fourth  of  all  the 
cases  of  nephritis  eclamptic  attacks  occur,  we  find  as 
the  result  that  one  case  of  nephritis  occurs  in  about  136 
cases  of  pregnancy."  ' 

Bartels  adduces  as  an  argument  against  the  cyanotic 
contracted  kidney  being  produced  by  mechanical  press- 
ure, the  fact  that  this  kidney  cannot  be  developed  in  a 
few  months.  To  this  it  may  be  answered  that  these 
cases  of  cyanotic,  indurated  kidney  may  be  the  result 


'  Bartels :  Ziemssen's  Cyclopfedia,  p.  311. 
7 


98  beigiit's  disease. 

not  of  one,  but  of  several  pregnancies.  This  was  the 
case  in  one  instance  where  the  patient  suffered  from 
albuminuria  in  six  pregnancies,  the  albumin  not  dis- 
appearing between  the  pregnancies. 

That  the  recognition  of  the  truth  of  the  theory  that 
the  albuminuria  of  pregnancy  is  produced  by  the  press- 
ure of  the  gravid  uterus  is  of  importance,  is  manifest 
from  the  fact  that  upon  its  acceptance  or  rejection  must 
sometimes  depend  the  decision  of  the  physician  whether 
good  will  be  done  by  producing  premature  delivery. 

Symptoms. 

Among  the  earliest  symptoms  are  an  increased  fre- 
quency of  micturition,  the  quantity  of  urine,  however, 
passed  in  the  twenty-four  hours  being  below  the  nor- 
mal— the  amount  of  urea  being  also  proportionally 
small.  The  reason  of  the  diminished  flow  of  urine  is 
probably  due  in  part  to  the  fact  that  the  cardiac  activity 
is  not  increased,  as  it  usually  is  in  interstitial  nephritis, 
but  often  diminished  ;  the  pressure  in  the  vessels  of  the 
glomerulus  being  thereby  lessened.  In  the  advanced 
stages  the  dropsical  effusions  take  the  place  of  urinary 
secretion. 

At  about  the  same  time  with  the  increased  frequency 
of  urination,  a  certain  amount  of  lassitude  is  developed. 
The  patient  experiences  a  loss  of  energy  and  physical 
strength.  These  symptoms  are  frequently  accompanied 
by  some  renal  pains  which  are  often  mistaken  for  rheu- 
matic pains  ;  persistent  and  intractable  headaches  and 
dyspeptic  symptoms  are  common.  These  conditions  do 
not  fail  to  be  followed  soon  by  the  tell-tale  oedema  pal- 
pebrarum, or  of  the  feet.  Nausea  usually  supervenes 
at  an  early  stage.  Where  the  disease  is  farther  ad- 
vanced there  is  emaciation,  often  marked  by  anasarca, 
dropsy  of  the  cavities,  and  also  cedema  of  the  mucous 
membranes,  lungs,  and  intestines. 


CHRONIC   CROUPOUS   NEPHRITIS — SYMPTOMS.  99 

It  is  in  this  form  of  nephritis  that  dropsical  affections 
are  most  frequent,  being  never  absent  and  assuming 
their  most  formidable  aspects,  sometimes  producing 
sloughing  of  the  cellular  tissues. 

Nausea  and  ursemic  symptoms,  as  blindness,  epilepti- 
form seizures,  and  coma,  are  much  less  frequent  than  in 
interstitial  nephritis.  According  to  Bartels  these  symp- 
toms, in  the  majority  of  cases,  are  entirely  absent. 
They  are  most  liable  to  occur  if  the  kidney  disease 
reaches  the  stage  of  atrophy. 

An  important  fact  concerning  the  existence  of  albumin 
in  this  form  of  nephritis  is  that  it  is  net)er  absent,  and 
is  often  present  in  much  larger  quantities  than  in  any 
other  form.  The  amount  of  uric  acid  excreted  does  not 
vary  much  from  the  normal. 

Though  a  scanty  secretion  of  urine,  sometimes  amount- 
ing to  complete  anuria,  is  characteristic  of  this  disease, 
in  cases  of  improvement  it  becomes  abundant,  and  in 
the  secondary  atrophy  it  may  even  be  more  profuse 
than  in  a  normal  condition. 

Urinary  casts  are  always  to  be  found,  the  granular 
cast  being  most  indicative  of  this  form  of  nephritis  and 
usually  predominating.  Hyaline  casts,  and  in  certain 
conditions  of  the  kidneys  waxy  and  fatty  casts,  may 
usually  be  found.  When  there  is  pyelitis  or  ulcerative 
destruction  of  the  kidney,  we  often  find  shreds  of  con- 
nective tissue.  Pus  corpuscles  and  epithelia  from  the 
tube  system  are  always  met  with.  A  few  blood  corpus- 
cles with  the  above  phenomena  in  the  urine  usually 
denote  chronic  croupous  nephritis  with  acute  recurrence. 
The  general  statement  of  Bartels  relative  to  the  import- 
ance of  casts  in  this  form  of  nephritis  is  so  truthful,  with 
the  exception  that  the  assertion  that  casts  "dotted  with 
isolated  dark  molecules  or  shining  fat  drops  denote 
nephritis  of  recent  existence  "  is  incorrect,  that  I  quote 
it  entire : 


100  bkight's  disease. 

"  So  long  as  tJie  casts  are  scanty^  the  greater  number 
of  them  present  characters  which,  in  my  opinion,  prove 
that  the  malady  is  of  recent  existence;  they  are  pale, 
hyaline,  or  slightly  streaked,  or  dotted  with  isolated 
dark  molecules  or  shining  fat  drops.  We  find  tliin, 
long,  and  slightly  curved  as  well  as  broad  casts,  and 
to  both  sorts  fragments  of  cells  or  white  blood  corpuscles 
adhere.  The  longer  the  process  has  lasted  the  more 
numerous  become  the  dark  granular  casts,  the  greater 
the  preponderance  of  the  broad  over  the  narrow  casts, 
and  the  more  abundant  those  peculiar  broad  yellow 
casts  of  wax-like  refracting  powers.^'' ' 

Diagnosis. 

The  diagnosis  of  croupus  nephritis  from  interstitial 
nephritis,  the  form  with  which  it  is  most  likely  to  be 
confounded,  is  not  usuall^^  attended  with  difficulties. 

The  following  table  presents  the  most  important  points 
of  difference  between  the  two  : 

In  Chronic  Okoupous  Nephritis.        In  Chronic  Interstitial  Ne- 
phritis. 

The  urine  is  always  albuminous.  Urine  not  constantly  albuminous. 

Urine  usually  scanty.  Generally  polyuria. 

Dropsy  and  oedema  almost  always  Dropsy  seldom  or  never  present ; 

exist.  sometimes  slight  oedema. 

Hypertrophy  of  the  heart  seldom  Some  hypertrophy  of  heart  with 

exists.  increased     arterial    tension     always 

present. 

Specific  gravity  of   urine   usually  Urine  generally   of   a  light   color 

higher    than     the    normal.      Urine  and  low  specific  gravity, 
darker  and  with  less  of  a  soapy  ap- 
pearancie  than  in  chronic  interstitial 
nephritis. 

Ursemic   symptoms    less   frequent  Ursemic  symptoms  occur   in  their 

than  in  chronic  interstitial  nephritis,  most  pronounced  form,  and  are  gen- 
erally present. 

^  Bartels,  in  Ziemssen's  Cyclopfedia. 


CHROXIC    CROUPOUS   NEPHRITIS — DIAGNOSIS.        101 

Lsr  Chroxic  Croupous  Nephritis.        In  Chroxic  Interstitial  Ne- 
phritis. 

Epistaxis  and  cerebral  hemorrhages  Epistaxis  and  cerebral  hemorrhages 
rare.  frequent. 

Occurs  most  frequently  before  the  Occurs  most  frequently  after  forty, 
age  of  forty. 

Blood   corpuscles   and   connective        Absent  in  chronic  interstitial  ne- 
tissue  shreds  more  frequently  found     phritis. 
in  chronic  croupous  nephritis. 

Development  more  gradual,  the 
health  of  patient  often  less  impaired, 
and  duration  longer  than  in  chronic 
croupous  nephritis. 

Casts  more  numerous  and  in  greater        Casts  rare  and  of  the  hyaline  va- 
variety  than   in   chronic    interstitial     riety. 
nephritis  ;  waxy,  granular,  fatty,  and 
hyaline  casts  occurring. 

Epithelia  from  the  kidney  and  pus        Kidney  epithelia  and  pus  corpus- 
corpuscles   more   numerous  than  in     cles  scanty, 
interstitial  nephritis. 

Urates  and  phosphates  predomi-  Oxalate  of  lime  almost  always  oc- 
nate  ;  oxalates  rare.  curs. 

Albuminous  retinitis  rare.  Albuminous  retinitis  common. 

Gangrenous  erysipelas  and  phleg- 
menous  swellings  more  common  ;  also 
dyspepsia  and  anaemia. 

Visceral    complications,    as    pneu-        Visceral  complications  rare. 
mouia.    pleuritis,    pericarditis,    and 
bronchitis,  not  uncommon. 

Diarrhoea  sometimes. 

Cirrhosis  of  liver  rare.  Cirrhosis  the  most  frequent  hepatic 

lesion. 

Atheroma  of  arteries  rare.  Atheroma  common. 

Course  and  Prognosis. 

It  may  be  stated  as  a  rule  tliat  the  prognosis  is  favor- 
able in  children  and  unfavorable  in  adults.  It  may  ter- 
minate favorably  or  unfavorably  in  a  few  months,  or  in 
exceptional  instances  it  may  exist  several  years  before 
it  proves  fatal.  If  it  have  existed  a  long  time  and 
dropsy  or  anasarca  have  supervened,  the  prognosis 
must  be  unfavorable.     Bright  re2;arded  this  form  as  in- 


102  bkight's  disease. 

curable.  The  prognosis  must  depend,  first,  upon  the 
organic  changes  in  the  kidney  so  far  as  can  be  shown 
by  the  microscope  and  the  chemical  examination  of 
the  urine.  If  casts  are  not  numerous  and  mostly  hya- 
line, if  there  are  but  few  kidney  epithelia  or  pus  cor- 
puscles, the  prognosis,  so  far  as  the  kidney  is  concerned, 
is  good.  But  if  there  be  indications  of  destructive  ul- 
ceration of  the  kidney,  of  fatty  or  waxy  degeneration, 
if  there  be  diminished  secretion  of  urine  with  a  deficient 
secretion  of  the  urinary  salts,  with  a  constantly  large 
percentage  of  albumin,  the  prognosis  is,  of  necessity, 
Unfavorable.  Second,  much  must  depend  upon  the 
etiology  of  the  case  and  the  patient's  constitution.  If 
the  result  of  some  chronic  suppurative  process,  or  if  it 
occur  in  a  scrofulous  cachectic  subject,  or  if  organic 
trouble  of  the  heart  exist,  the  prognosis  is  necessarily 
more  unfavorable  than  if  it  occur  in  a  person  possessing 
a  constitution  naturally  good,  and  whose  vital  powers, 
nutritive  functions,  etc.,  are  still  unimpaired.  The  ten- 
dency of  chronic  croupous  nephritis  is,  however,  to  a 
shorter  existence  than  that  of  chronic  interstitial  ne- 
phritis. 

That  cases  of  chronic  croupous  nephritis  recover  there 
is  no  doubt,  but  I  think  recoveries  take  place  when  a 
limited  portion  only  of  the  renal  connective  tissue  and 
intratubular  elements  are  affected.  If  the  intertubular 
spaces  are  widened,  or  many  of  the  tubules  contracted 
or  obliterated,  if  the  connective  tissue  be  infiltrated 
with  inflammatory  corpuscles  and  a  great  portion  of 
the  tubules  denuded  of  their  epithelia,  the  Malpighian 
tufts  atrophied  or  their  capsules  filled  by  exudation, 
crowding  the  tuft  literally  into  a  corner,  or  their  connec- 
tive tissue  thickened  and  the  epithelia  covering  them 
converted  into  shining  lumps  of  matter  or  into  inflamma- 
tory corpuscles,  the  kidney  itself  greatly  enlarged  or 
atrophied,  not  much  is  to  be  looked  for  in  the  way  of 


CHEONIC   CROUPOUS   NEPHRITIS — PATHOLOGY.        103 

recovery.  If  the  nephritis  have  a  syphilitic  origin,  it  is 
remarkable  with  what  rapidity  it  will  sometimes  disap- 
pear ^«r/^a55zc  with  the  syphilitic  symptoms  upon  the 
employment  of  anti-syphilitic  remedies. 

Bartels,  in  "  Ziemssen's  Cyclopaedia,"  gives  the  details 
of  a  case  of  supposed  amyloid  degeneration  of  the  kid- 
ney and  liver  as  resulting  from  syphilis,  but  which,  from 
his  description,  seems  to  be  chronic  croupous  nephritis, 
which  was  cured  entirely  by  the  administration  of  the 
iodide  of  potassium  and  hot  baths. 

The  case  is  that  of  a  young  lady  whose  father  had 
been  syphilitic.  The  patient  had  anasarca  and  dropsy 
of  the  abdomen  ;  the  legs  were  of  unequal  length  ;  the 
spleen  was  greatly  enlarged ;  the  urine  was  passed  in 
sufficient  quantities,  was  dark,  clear,  and  contained  few 
casts  but  a  great  deal  of  albumin.  She  also  suffered 
from  nasal  catarrh  and  deafness,  and  a  large  portion  of 
the  bony  septum  of  the  nose  was  destroyed. 

The  albumin  persisted  for  a  long  time,  but  after  about 
a  year's  treatment  she  was  dismissed  cured  of  the  en- 
larged spleen,  anasarca,  dropsy,  and  albuminous  urine. 
Five  years  later  none  of  these  symptoms  had  returned. 

Pathology. 

Macroscopic  Appearances. 

These  differ  greatly,  as  the  effects  of  chronic  croupous 
nephritis  upon  the  kidney  are  so  various.  In  the  ' '  large 
toliite  Mdney  "  the  enlargement  is  sometimes  very  great ; 
the  surface  is  smooth,  the  capsule  non-adherent  and 
thin  ;  there  is  an  absence  of  depressions,  and  the  lobular 
structure  externally  is  effaced.  The  cortical  substance 
is  thickened,  is  whitish  or  yellowish,  and  there  is  an 
absence  of  striations  ;  lardaceous  or  waxy  and  fatty 
changes  are  very  common,  and  it  is  in  this  type  of  ne- 


104  bright' S   DISEASE. 

pliritis  that  we  meet  with  them  in  their  most  pronounced 
form.  Cysts  are  more  numerous  than  in  interstitial  ne- 
phritis. 

The  atropMed  or  contracted  Mdney  is  small,  some- 
what dense,  but  less  firm  than  the  chronic  cirrhotic 
kidney  ;  the  surface  is  undulated  and  uneven. 

"In  transverse  sections  of  a  kidney  of  this  kind  we 
find  that  the  cortical  substance  is  absent  in  those  places 
corresponding  with  the  retractions  of  the  surface,  while 
in  other  places  the  cortical  substance  may  be  unaltered 
or  even  increased  in  bulk."  '  The  general  coloration  of 
the  cortical  substance  is  pale  and  yellowish. 

The  kidney  sometimes  will  be  reduced  to  an  ounce  in 
weight.  The  decrease  in  bulk  is  mainly  due  to  the  oblit- 
eration of  the  tubules,  which  are  not  replaced  as  in  cir- 
rhosis by  connective  tissue.  Atrophy  is  at  the  expense 
of  the  cortical  substance.     The  capsule  is  thickened. 

Microscopic  and  Histological. 

Of  course  the  microscopic  examination  shows  many 
points  of  resemblance  between  chronic  and  acute  croup- 
ous nephritis.  As  regards  the  intratubular  changes  in 
the  former,  we  find  usually,  except  in  atrophy  or  fatty 
or  waxy  degeneration  involving  the  greater  part  of  the 
kidney,  some  of  the  tubules  presenting  the  cloudy 
swelling  of  the  epithelia,  as  described  in  acute  croup- 
ous nephritis  in  its  early  or  advanced  stage.  The  rod- 
like structure  of  the  epithelia,  generally  thickened  and 
bulky,  I  have  found  in  this  form  of  nephritis  in  the 
straight  tubules,  also  in  chronic  croupous  nephritis  with 
waxy  degeneration  in  the  ascending  tubules,  and  in  the 
straight  tubules  in  the  pyramid  of  the  same  kidney. 
(See  Fig.  17,  A.)  Also  in  the  convoluted  tubules,  with 
and  without  fatty  degeneration.     (Fig.  17,  C,  B,  D.) 

'  Greene,  in  Heitzmann's  Morphology. 


CHROIS'IC   CROUPOUS   NEPHRITIS — MICROSCOPIC,      105 

Except  where  the  whole  kidney  is  involved,  some  sec- 
tions will  show  the  epithelia  unaffected ;  some  will  be 
found  enormously  enlarged  or  partially  disintegrated ; 
some  will  contain  inflammatory  or  pus  corpuscles,  while 
others  are  so  attenuated  as  to  be  almost  transparent.  In 
many  cases  the  epithelia  are  desquamated  and  fill  par- 
tially or  entirely  the  tubule,  or  only  the  empty  tubule 


Fig.  17.— a.  Chronic  Croupous  Nephritis — Straight  Tubule. — Granular  swelling  of 
the  epithelia,  showing  rods  and  reticular  structure.     (Magnified  1,000  diameter.s. ) 

B,  Fattt  Degeneration  of  the  Kidnet. — Cross-section  of  convoluted  tubule.  Cloudy 
swelling  of  epithelia,  showing  rods  and  fat  granules.  Connective  tissue  thickened.  (Magnified 
600  diameters.) 

C,  Chronic  Croupous  Nephbitis  with  Waxy  Degeneration,  showing  rods  rather  en- 
larged. Cross-section  of  ascending  tubule.  A,  droplets  of  waxy  exudation.  (Magnified  600 
diameters.) 

will  be  found,  the  epithelia  having  perished  ;  in  others, 
waxy,  fatty,  hyaline,  or  granular  casts  will  be  found, 
some  having  epithelia,  and  some  the  remnants  of  nuclei 
adhering  to  them,  casts  always  being  met  with  in  this 
form  of  nephritis.  The  tubules  will  sometimes  be 
choked  up  with  inflammatory  and  pus  corpuscles,  and 
sometimes  with  granular  matter  and  indifferent  forma- 
tions. Blood  is  not  common  except  in  case  of  hemor- 
rhage.    It  is  in  this  form  of  nephritis  that  we  most  fre- 


106 


beight's  disease. 


quently  find  the  epithelia  destroyed  and  replaced  by 
endotlielia.  Portions  of  the  epithelia  may  have  under- 
gone, wholly  or  in  part,  fatty  or  waxy  degeneration. 


Pig.  18. — Chbonio  CEOrPOus  Nephritis.— A,  convoluted  tubule  filled  with  nuclei,  granular 
matter  from  broken-down  epithelia,  and  indifferent  elements  ;  B,  endothelia  ;  C,  granular  oast 
surrounded  by  endothelia  ;  D,  homogeneous  shining  lumps  of  matter  formed  from  the  nuclei 
of  the  epithelia;  B,  hyaline  cast  surrounded  by  endothelia;  F,  epithelia  converted  into  amy- 
loid or  waxy  corpuscles.  These  are  shown  by  the  clear  ones  in  the  centre.  The  tr-insition 
from  the  normal  epithelia  is  shown  by  those  on  the  left.  O,  wasted  and  attenuated  epithelia  ; 
H,  widened  structureless  membrane ;  I,  atrophied  tuft ;  J,  space  between  capsule  and  tuft  filled 
with  connective  tissue ;  K,  thickened  capsule ;  L,  inflammatory  corpuscles  ;  M,  epithelia  of 
straight  tubule,  coarsely  granular;  N,  cross-section  irregular  tubule,  do.,  do.  ;  O,  cross-section 
portion  of  narrow  tubule,  do.,  do.;  P,  thickened  connective  tissue.    (Magnified  500  diameters.) 


The  partially  disintegrated  epithelia  may  be  found  to 
be  interspersed  with  shining  fat  granules. 
Fat  may  be  developed  in  any  of  the  tissues  of  the 


CHRONIC   CROUPOUS   NEPHRITIS — MICROSCOPIC.      107 

kidney.    Its  development  in  tlie  epitiielia  from  particles 
of  the  living  matter  of  the  reticulum  can  be  shown. 

It  is  often  easy  to  trace  the  formation  of  a  cast,  the 
epithelia  sometimes  being  found  to  be  saturated  with 
droplets  of  exudate  gradually  moulding  them  into  a 
cast.     (See  Figs.  10  and  11.) 


Fig.  19. — Fatty  Degeneration  op  the  Kidney— High  Degree.  (Large  White  Kid- 
ney)—Chronic  Croupous  Kephritis.  Spaces  greatly  widened. — A,  fatty  cast ;  B,  broken- 
down  epithelia  showing  fat  globules  ;  C,  fat  globules  in  the  connective  tissue  ;  D,  endothelia ; 
E,  nuclei  of  epithelia,  some  having  undergone  the  fatty  change  ;  F,  inflammatory  corpuscles ; 
G,  tubule  with  granular  matter ;  II,  epithelia  undergoing  the  fatty  change  ;  I,  epithelia  partly 
broken  down  or  showing  fatty  change.    (Magnified  500  diameters.) 

In  other  cases  the  waxy  cast  partially  formed  in  the 
same  manner  will  be  found.  (See  Figs.  17,  C,  and 
18,  F.) 

When  a  cast  is  found  in  a  tubule  surrounded  by  the 
epithelia  in  situ,  it  may  be  assumed  that  it  has  migrated 
and  not  formed  there.  In  atrophy  of  the  kidney  the 
tubules  will  be  found  mostly  obliterated  or  only  traces 
of  them  left,  their  configuration  being  entirely  lost.  It 
is  probable  that  the  epithelia  enter  into  the  formation 
of  the  inflammatory  corpuscles  scattered  throughout. 
There  is  some  proliferation  of  the  connective  tissue 


108  bright' S   DISEASE. 

around  the  tubules,  thougli  it  is  more  delicate  than  in 
chronic  interstitial  nephritis ;  it  is  less  uniformly  dis- 
tributed than  in  cirrhosis  ;  it  may  be  homogeneous  or 
vascular,  and  has  a  scanty  supply  of  blood-vessels. 
Nevertheless  the  intertubular  connective  tissue  is  often 
increased,  but  not  striated  as  in  cirrhosis.  (See  Fig. 
18,  P.)  Pervading  it  will  usually  be  found  pus  or  in- 
flammatory corpuscles.  In  Fig.  18  the  connective  tissue 
is  seen  to  be  considerably  increased.  Sometimes  this 
will  be  found  to  have  undergone  a  fatty  or  waxy  degen- 
eration. Many  of  the  blood-vessels  will  be  inflamed 
and  affected  also  by 


Waxy  Degeneration. 

It  is  not  exactly  known  what  the  blood  changes  are 
that  produce  this  waxy  amyloid,  or  lardaceous  change, 
as  it  is  variously  called.  It  occurs  often  when  there  is 
some  dyscrasia,  as  syphilis,  chronic  abscesses,  prolonged 
sujopuration,  Pott' s  disease,  caries,  etc.  It  is  undoubt- 
edly, in  the  language  of  Heitzmann,  "due  to  a  chemical 
change  in  the  plasma  of  the  blood,  as  it  is  sometimes 
found  in  hemorrhagic  clots,  independent  of  or  combined 
with  analogous  tissue  changes." 

Bartels  states  that  the  disease  occurs  most  frequently 
in  the  suppurative  processes  associated  with  actual 
ulceration,  and  consequently  molecular  necrosis  of  the 
tissues.  Dickinson,  on  the  strength  of  its  association 
with  suppurative  processes,  founds  an  explanation  of 
the  disease  upon  a  humoral  theory.  He  states  that  the 
amyloid  matter  is  only  fibrin  deprived  of  its  free  alkali. 
The  fallacy  of  his  arguments  could  be  easily  shown,  but 
too  much  space  would  be  required.  I  may  say  briefly, 
however,  that  if  his  theory  were  correct,  amyloid  degen- 
eration would  ensue  upon   all  cases  of   extreme  sup- 


WAXY   DEGENERATION.  109 

puration,  as,  for  instance,  empysemia,  whether  or  not 
pus  were  exposed  to  tlie  air.  Nor  even  without  this 
exception  would  the  theory  be  entirely  applicable,  inas- 
much as  it  often  occurs  without  prolonged  suppuration, 
as  in  some  cases  of  syphilis,  chronic  articular  rheuma- 
tism, and  some  forms  of  cancers,  and  is  in  a  greater  or 
less  degree  found  in  nearly  all  cases  of  chronic  croup- 
ous nephritis  of  a  severe  character. 

When  the  kidney  has  been  stained  by  carmine  the 
parts  affected  by  waxy  degeneration  have  a  glassy, 
bright,  and  clear  appearance ;  the  parts  thus  affected 
readily  take  the  carmine  stain. 

"The  epithelia of  the  tubules  which  have  in  a  measure 
escaped  the  iniiammatory  action,  may  become  the  seat 
of  waxy  degeneration  when  a  similar  condition  has 
reached  an  advanced  stage  throughout  the  kidney  tis- 
sue."' 

The  connective  tissue,  the  memhrana  propria  or  base- 
ment membrane  of  the  tubules,  the  blood-vessels,  and 
the  Malpighian  tufts,  all  may  show  the  change :  the 
atrophied  tuft  is  usually  affected  ;  it  seems  to  occur  in  all 
these  simultaneously ;  at  least,  I  have  never  found  the 
blood-vessels  of  the  kidney  affected  exclusively.  Usually 
the  middle  coat  of  the  arteries  is  affected  before  the 
capillaries.  The  statement  in  Charcot '^  that  "as  to 
Henle's  loops  it  does  not  appear  that  they  are  ever 
altered,"  I  have  found  by  repeated  observations  to  be 
erroneous.  Epithelia  unaffected  by  waxy  degeneration 
do  not  so  readily  take  the  carmine  stain  as  the  con- 
nective tissue.  The  waxy  matter  takes  the  place  of  the 
normal  structure  of  the  affected  tissue. 

May  waxy  degeneration  of  the  kidney  exist  without 
nephritis?  I  have  never  seen  and  never  been  able  to 
obtain  evidence  of  the  existence  of  such  a  case.    A  care- 

'  Greene,  in  Heitzmann's  Morphology.  ^  Bright's  Disease. 


110 


beight's  disease. 


ful  analysis  of  tlie  reports  of  such  cases  affords  no 
evidence  that  amyloid  degeneration  without  inflamma- 
tion existed.  In  the  'case  reported  by  Bartels  there 
is  no  positive  evidence,  as  the  patient  recovered,  that 
amyloid    degeneration  existed  at    all.      Nevertheless, 


Pig.  20. — Waxy  Degeneration  of  the  Kidney— Chronic  Croupous  Nephritis. — A, 
■waxy  cast ;  B,  capillary  with  waxy  walls,  6  &  ;  C,  medullary  rays  with  incipient  waxy  walls ; 
D,  ai  tery  transverse  section  in  waxy  degeneration;  E,  epithelia  and  nuclei ;  part  undergoing 
waxy  change.     (Magnified  500  diameters.) 

though  it  is  thought  by  some  writers  that  amyloid  de- 
generation of  the  kidney  exists  without  inflammation, 
it  does  not  seem  to  me  that  the  writers  who  so  maintain 
have  succeeded    in   demonstrating   the  correctness  of 


CHRONIC   CROUPOUS    NEPHRITIS — CHANGES. 


Ill 


their  belief.  Dickinson,  for  example,  in  the  description 
he  gives  of  the  histological  changes  in  the  lardaceous 
kidney,  shows  that  in  each  case  the  nephritis  was  clearly 
marked,  the  form  being  usually  chronic  croupous  ne- 
phritis. He  observes  that  "the  disease  is  easy  to  re- 
cognize during  life,  perhaps  more  so  than  either  of  the 
other  forms  of  renal  disease."  "The  urine,"  he  says, 
"is  albuminous." 
In  chronic  croupous  nephritis  many  changes  may  be 


Fig.  21. — Chronic  Croupoos  Nephritis. — A,  columnar  epithelia  showing  cloudy  swelling  ; 
B,  tuft  full  of  shining  granules  ;  C,  space  between  capsule  and  tuft  filled  with  thickened  con- 
nective tissue  ;  D.  convoluted  tubule  filled  with  a  naass  of  hyaline  and  granular  matter.  (Mag- 
nified SOU  diameters.) 

looked  for  in  the  tuft  and  its  capsule  ;  in  some  instances 
the  vessels  will  be  enormously  distended  and  covered 
with  inflammatory  granules  or  corpuscles,  in  others  the 
tuft  is  thickened  and  solidified,  the  intracapsular  con- 


112  bright' S   DISEASE. 

nective  tissue  also  being  thickened.  In  the  kidney  from 
which  the  drawing  of  Fig.  18  was  taken  there  was  also 
some  cirrhosis.  In  other  cases  the  tuft  is  greatly 
atrophied.  Sometimes  the  space  between  the  tuft  and 
capsule  will  be  crowded  with  inflammatory  corpuscles, 
the  capsule  itself  being  greatly  thickened.  (Fig.  18, 
K  and  L.) 

I  have  met  with  cases  where  the  tuft  was  crowded  and 
compressed  into  a  small  space  by  a  sero-albuminous 
fluid  filling  the  capsule.     (See  Fig.  24,  K  and  J.) 

In  the  large  white  kidney  the  tubules  and  intertubu- 
lar  spaces  are  often  widened. 

This  form  of  the  kidney  is  frequently  infiltrated  with 
fat  and  greatly  increased  in  bulk. 

Of  Cysts. 

There  are  numerous  theories  concerning  the  formation 
of  these.  One  that  they  are  formed  from  the  capsule  or 
tuft,  another  from  the  mechanical  blocking  up  of  the 
tubules.  I  have  found  no  explanation  so  satisfactory 
as  that  of  Dr.  J.  B.  Greene,  in  Heitzmann's  "Mor- 
phology" (p.  775) : 

"  The  first  thing  noticed  is  an  abundant  formation  of 
inflammatory  corpuscles  in  circumscribed  districts  of 
the  kidney  tissue.  These  may  be  situated  in  the  cortex 
or  in  the  pyi^amidal  substance.  Many  of  these  corpus- 
cles evidently  originated  from  tubular  epithelia.  The 
second  stage  is  characterized  by  the  swelling  of  the  in- 
flammatory bodies,  which  afterward  become  pale,  and 
by  a  process  of  liquefaction  or  mucoid  degeneration  are 
transformed  into  a  hyaline,  apparently  structureless 
mass.  We  frequently  find  in  this  mass  delicate  granu- 
lar fibres,  which  resemble  those  of  myxomatous  tissue. 
The  new  formation  thus  produced  may,  at  the  outset, 
be  extremely  small  and  irregularly  bounded  by  un- 


OF   CYSTS.  113 

changed  medullary  corpuscles.  With  the  growth  of 
the  cyst  more  medullary  bodies  gradually  become  lique- 
fied, till  at  length  a  cavity  is  established  containing  a 
sero-albuminous  fluid,  and  bounded  by  flattened,  poly- 
hedral, medullary  corpuscles,  which  in  this  situation 
might  be  designated  endothelia.  At  the  periphery  a 
formation  of  fibrous  basis-substance  takes  place,  with 
the  production  of  a  capsule — the  cyst-wall  proper. 
Cysts,  therefore,  are  the  products  of  secondary  changes 
of  medullary  bodies  which  had  their  origin  in  kidney 
epithelia." 

This  description  of  the  formation  of  cysts  is  the  more 
satisfactory  to  me,  as  I  had  the  opportunity  of  seeing 
many  of  the  specimens  from  which  Dr.  Greene's  conclu- 
sions were  formed,  while  the  studies  were  being  made. 
8 


CHAPTER  XVI. 

SUPPUKATIVE  NEPHRITIS. 

This  is  most  frequently  caused  by  the  extension  of  in- 
flammation from  the  bladder.  It  may  result  from  in- 
tense pyelitis,  or  acute  croupous  hemorrhagic  nephritis. 
Diphtheria  and  acute  infectious  diseases,  embolism, 
pysemia,  and  the  use  of  dirty  sounds  or  catheters,  am- 
moniacal  putrefied  urine,  bacteria,  and  vesical  irritation 
from  the  presence  of  calculi,  all  may  produce  it.  One 
or  both  kidneys  may  be  affected.  The  abscesses  may 
be  limited  to  one  or  two,  or  may  be  very  numerous, 
riddling  the  whole  kidney  or  converting  it  into  a  semi- 
liquid  purulent  mass.  In  this  form  of  nephritis  there 
is  always  croupous  nephritis  (tuberculosis  of  the  kid- 
neys always  being  accompanied  by  interstitial  nephri- 
tis). Abscesses  are  always  found  ;  they  are  most  nu- 
merous in  the  cortical  substance,  varying  in  size  from  a 
millet  seed  to  that  of  a  chestnut.  In  a  suppurative 
kidney  it  is  easy  under  a  power  of  x  500  to  trace  all  the 
gradations  of  croupous  nephritis  leading  to  the  destruc- 
tion of  the  tissue  and  its  conversion  into  pus.  In  many 
portions  of  the  kidneys  the  tubules  present  simply  the 
phenomena  existing  in  acute  croupous  nephritis,  as 
cloudy  swelling,  disintegrated  and  broken-down  epithe- 
lia,  granulations,  and  pus  corpuscles,  or  a  mass  of  hya- 
line matter.  In  the  tubules,  however,  lying  near  the 
foci,  the  epithelia  will  be  found  to  contain  lumps  of 
shining  matter,  varying  in  size.  Their  connection  with 
the  coarse  granular  matter  of  which  they  are  formed 
can  be  traced  {vide  p.  11). 


SUPPURATIVE   NEPHRITIS. 


115 


Again,  these  shining  lumps  will  be  found  to  be  ad- 
vanced to  the  condition  of  medullary  corpuscles,  and 
these  in  turn  converted  into  pus  corpuscles.  The  epi- 
tlielia  of  the  affected  portion  becomes  changed  entirely 
into  the  above  nucleated  formations  ;  the  connection  be- 
tween the  inflammatory  corpuscles  and  granular  matter 
exists  until  the  former  become  pus  corpuscles,  when  it 


ft  I'm  I  ■. 


'is© 

mm 


Fig.  22. — Suppurative  Nephritis  (Abscess  of  Kidney)  — A,  convoluted  tubule,  filled  with 
pus  corpuscles  and  lined  by  endothelia  ;  B,  broken-down  epithelia ;  C,  tubuli  nearly  obliter- 
ated ;  D,  pus  corpuscles  ;  E,  increased  and  greatly  augmented  nuclei ;  F,  inflammatory  cor- 
puscles :  Gr,  tubule  with,  nearly  unchanged  epithelia ;  H,  structureless  membrane.  Magnified 
5(.iO  diameters.     (See  also  Fig.  16.) 

is  severed  (Heitzmann).  The  blood-vessels  are  dilated, 
the  tufts  swollen  and  covered  with  coarsely  granular 
nuclei  or  inflammatory  corpuscles.  The  connective  tis- 
sue is  oedematous  and  filled  with  globular  or  coarsely 
granular  nuclear  bodies.  It  seems  loaded  with  shining 
lumps,  finally  differentiating  into  nucleated  or  inflam- 
matory corpuscles  and  these  into  pus. 

"Only  when  the  continuous  mass  is  torn  into  separate 


116  beight's  disease. 

nucleated  lumps  have  we  to  deal  with  finished  pus.  The 
tissue  is  destroyed — in  its  place  we  have  an  abscess." 
(Greene,  in  Heitzmann's  "  Morphology.") 

Diagnosis, 

The  diagnosis  of  suppurative  nephritis,  when  the  ab- 
scesses are  small,  is  not  easy,  sometimes  impossible. 
Pyelitis,  accompanied  with  an  amount  of  pus  in  the 
urine  that  is  not  the  result  of  cystitis  or  any  other  as- 
signable cause,  and  with  not  enough  kidney  epithelia  to 
show  excessive  croupous  nephritis,  would  probably  in- 
dicate the  existence  of  suppurative  nephritis.  The 
diagnosis  must  be  aided  by  the  history  of  the  case.  In 
extensive  abscesses  the  engorged  kidney  can  sometimes 
be  felt  through  the  abdominal  parietes  and  in  the  loins. 
Movement  produces  intense  pain,  which  may  extend  into 
the  inguinal  region  or  testicles.  Rigors,  vomiting,  or 
fever  may  occur.  Blood  can  always  be  found  under  the 
microscope.  The  amount  of  urine  is  always  diminished 
— sometimes  suppressed. 

COUESE   AND   PeOGNOSIS. 

These  must  depend  upon  the  cause  and  extent  of  the 
nephritis.  Large  abscesses  may  open  into  the  perito- 
neal cavity  or  into  any  of  the  neighboring  viscera,  or 
they  may  open  into  the  pelvis  and  heal  up.  The  con- 
tents of  the  small  ones  may  sometimes  be  converted  into 
a  calcareous  mass,  the  liquid  being  absorbed.  The  kid- 
ney may  sometimes  be  almost  restored  to  health,  partic- 
ularly if  the  exciting  cause  be  removed.  The  progno- 
sis is,  however,  usually,  as  regards  a  cure,  unfavorable, 
and  when  due  to  pyaemia,  or  the  abscesses  are  extensive, 
always  so.  Still  such  a  degree  of  recovery  may  take 
place  that  patients  will  enjoy  a  tolerable  degree  of  health 
in  cases  of  abscesses  due  to  calculi  or  severe  cj^stitis, 
when  these  causes  have  been  removed. 


CHAPTER  XYII. 

CATARRHAL  OR  INTERSTITIAL  NEPHRITIS. 

This  form  of  nephritis  is  generally  known  as  interstitial 
or  desquamative  nephritis.  Charcot  calls  it  ^'' primitwe 
cJironic  interstitial  nephritis, ^^  and Lecorche,  "hyper- 
plastic interstitial  nephritis."  It  is  this  form  that  brings 
about  the  changes  in  the  kidney  known  as  the  con- 
tracted kidney,  granular  atrophy  of  the  kidney,  renal 
cirrhosis,  renal  sclerosis,  and  granular  degeneration. 
The  term  interstitial  is  not  wholly  suitable,  as  it  indi- 
cates the  lesion  to  be  one  of  the  connective  tissue,  while 
the  name  desquamative  is  incorrect,  as  the  inflammation 
is  not  simply  one  the  principal  result  of  which  is  the 
desquamation  of  the  epithelia.  Both  these  lesions  co- 
exist, sometimes  in  an  equal  degree  ;  in  other  cases  the 
changes  in  the  interstitial  tissue,  tufts,  or  tubules  being 
most  markedly  pronounced.  These  two  appellations 
define  no  more  accurately  the  topography  of  the  lesions 
than  does  the  glomerulo-nephritis  of  Klebs,  which  is  al- 
ways present  in  this  and  in  croupous  nephritis.  I  con- 
sider the  term  catarrhal,  first,  I  believe,  applied  to  this 
inflammation  by  Yirchow,  as  most  appropriate,  produ- 
cing as  it  does  infiltration  of  the  connective  tissue  with 
cloudy  swelling  and  desquamation  of  the  epithelium. 
]S"evertheless,  as  the  form  of  nephritis  in  question  has 
for  so  long  a  time  been  designated  as  interstitial,  I  shall, 
as  a  matter  of  convenience,  retain  this  term.  The  nature 
of  interstitial  nephritis,  according  to  Heitzmann,  whose 
description  I  have  repeatedly  verified,  consists  in  oede- 
jiiatous  infiltration   of  the  connective  tissue,    causing 


118  bright' S   DISEASE. 

striation  of  the  swelled  cortical  substance  ;  "  the  stria- 
tion,"  according  to  this  author,  being  "most  marked 
between  the  cortical  and  pyramidal  substances,"  the 
seat  of  the  disease  being  principally  the  connective  tis- 
sue between  the  tubules,  the  exudation  into  the  tubules 
causing  desquamation  of  the  epithelia  but  not  often 
casts,  as  are  produced  in  croup  of  the  mucous  membrane. 
Casts  are  rare,  and  only  the  hyaline  are  found  ;  albu-. 
min  is  frequently  absent,  and  sometimes  is  not  found 
in  the  whole  course  of  the  disease.  The  striations  are 
strongly  marked,  both  in  acute  and  chronic  interstitial 
nephritis  (cirrhosis),  even  in  the  highest  degree  of  cir- 
rhotic atrophy. 

The  striations  form  dense  concentric  layers  around 
the  tubular  tufts  and  blood-vessels.  Desquamated  epi- 
thelia and  a  few  pus  corpuscles  are  found  in  the  urine. 
Fatty  degenerations  and  cysts  are  less  common  than  in 
croupous  nephritis  ;  suppuration  does  not  occur.  Hy- 
perplasia of  the  connective  tissue  may,  in  the  early 
stages,  produce  hypertrophy ;  in  advanced  stages  the 
epithelia,  connective  tissue,  and  many  of  the  capillaries 
become  transformed  into  an  indifferent  or  medullary 
tissue.  The  renal  tissue  finally  becomes  atrophied, 
"resulting  in  the  formation  of  the  small,  contracted 
granular  or  cirrhotic  kidney"  (Meyer).  The  blood-ves- 
sels and  tubules  become  obliterated  and  are  replaced  by 
connective  tissue.  The  surface  of  the  cirrhotic  kidney 
is  different  from  the  kidney  affected  by  croupous  in- 
flammation ;  it  shows  fine  granulations  and  only  shal- 
low furrowings  or  indentations,  with  a  corresponding 
striation  of  the  cortical  layer,  while  in  the  atrophy  of 
croupous  nephritis  the  surface  is  coarsely  lobulated, 
there  sometimes  being  large  nodes  separated  from  each 
other  by  deep  furrows,  and  in  croupous  nephritis  there 
is  a  grayish-yellow  infiltration  in  the  irregular  atrophied 
cortical  layer. 


CHAPTER  XVIII. 

ACUTE   AND   CHRONIC   INTERSTITIAL   NEPHRITIS. 

Though  Charcot  calls  interstitial  nephritis  ^'-primitive 
chronic  interstitial  nepTiritis^''''  it  has  an  acute  begin- 
ning and  there  is  an  acute  form.  I  believe,  however, 
that  it  is  a  very  rare  exception  when  the  acute  form  has 
been  discovered  before  the  chronic  has  been  reached. 
The  obstacles  to  the  early  discovery  of  interstitial 
nephritis  in  its  mild  or  latent  form  are  so  numerous, 
the  physical  condition  of  the  patient  is  often  so  favora- 
ble, the  absence  of  nausea  or  oedema,  or  of  ursemic 
symptoms — the  non-employment,  perhaps,  of  the  micro- 
scope— prevent,  as  a  rule,  any  recognition  of  interstitial 
nephritis  till  the  chronic  form  has  been  established ; 
and  it  is  perhaps  these  facts  which  have  induced  Char- 
cot to  employ  the  nomenclature  he  has.  Still,  an  acute 
form  exists  and  is  easily  recognizable  under  the  micro- 
scope. I  believe  that  in  the  interstitial  nephritis  caused 
by  gout,  lead,  syphilis,  and  perhaps  tuberculosis,  the 
inflammation  is,  however,  so  lentescent  in  its  develop- 
ment as  almost  always  to  be  chronic  in  its  character. 
Still,  the  microscope  shows  different  morphological  con- 
ditions. 

Acute  interstitial  nephritis,  when  it  occurs,  I  believe 
to  be  in  nearly  all  cases  the  result  of  cold  or  of  exten- 
sion of  severe  or  chronic  cystitis,  which  in  a  majority  of 
cases  affects  the  kidney  to  a  greater  or  less  extent. 


120 


bright' S   DISEASE. 


Etiology  of  Acute  and  Cheonic  Interstitial 
Nephritis. 

The  etiology  of  acute  and  clironic  interstitial  nephrit- 
is, and  the  characteristics  and  features  of  the  two  dis- 
eases, are  so  much  alike  that  it  is  unnecessary  to  mul- 
tiply divisions  by  considering  their  causes  separately. 

Ages  at  whicJi  it  Occurs. 

As  croupous  nephritis  is  a  disorder  of  early  life,  in- 
terstitial nephritis  is  of  later,  or  middle  life.  As  a  re- 
sult of  vesical  inflammation,  or  some  similar  exciting 
cause,  it  might  occur  at  any  age  ;  but  aside  from  being 
produced  by  the  extension  of  local  inflammation,  it  is 
not  likely  to  make  its  appearance  under  the  age  of 
twenty.  I  have  noted  the  ages  of  93  of  the  patients 
whose  urine  I  have  examined  in  interstitial  nephritis, 
and  find  that  of  two  cases  of  these  one  occurred  in  a 
young  lady  at  the  age  of  seventeen,  the  attack  being  in- 
duced, so  far  as  could  be  recognized,  by  cold  (see  Case 
XI.),  the  other  occurring  in  a  tubercular  young  man, 
aged  nineteen.  This  patient  had  been  a  great  sufferer 
from  malarial  poisoning.  Tyson '  says  the  youngest 
patient  he  ever  had  affected  by  interstitial  nephritis 
was  twenty-six  years  old.  Dickinson  gives  a  table  of 
308  cases,  and  Bartels  of  33,  of  interstitial  nephritis, 
representing  the  ages  at  which  the  disease  occurred  or 
was  recognized.  My  own  93  cases  added  to  these  make 
434  cases,  constituting  the  following  table : 

Occurring  under  20,     ....        6 
Between  20  and  30,     ....      35 

84 

127 

108 

Over         60,         .  '     .         .         .         .74 


30 

"    40, 

40 

"    50, 

50 

"    60, 

60, 

, 

434 


'  Bright's  Disease,  p.  169, 


INTERSTITIAL   NEPHRITIS — CAUSOLOGY.  121 

Dickinson  mentions  the  case  of  "a  kidney  in  a  typi- 
cal state  of  granular  contraction  wliicli  had  been  taken 
from  the  body  of  a  girl  only  five  years  of  age,"  and  also 
a  patient  who  died  at  the  age  of  ten  with  a  most  marked 
condition  of  granular  contraction,  affecting  especially 
one  kidney. 

Acute  and  Chronic  Interstitial  Nephritis. 

Their  Comparative  Prevalence  in  tlie  Sexes. 

Undoubtedly  interstitial  nephritis  occurs  more  fre- 
quently in  males  than  in  females,  I  think  the  explana- 
tion of  this  is  to  be  found  mainly  in  the  fact  that  the 
male  sex  undergoes  more  exposure  to  unfavorable  atmo- 
spheric influences,  and  that  the  same  sex  is  more  liable 
to  renal  and  urethral  inflammations,  as  well  as  to  cal- 
culus. 

GrENERAL    CaTJSOLOGT. 

The  most  frequent  cause  of  interstitial  nephritis  I 
believe  to  be  damp  cold  and  "catching  cold."  It  oc- 
curs most  in  temperate  zones,  and  in  these  zones  in 
such  parts  as  experience  the  most  violent  changes  in 
temperature.  It  seems  unknown  in  the  arctic  regions, 
and  is  infrequent  in  sub-tropical  regions  and  the  tropics. 
Dickinson's  theory  of  its  comparative  prevalence  as  re- 
gards climate  is  as  follows  : 

"The  prevalence  of  the  disorder  in  temperate  climates 
may  probably  be  explained  by  the  axiom  that  the  lia- 
bility of  an  organ  to  disease,  particularly  to  inHamma- 
tor}^  disease,  bears  a  general  proportion  to  its  func- 
tional activity.  The  respiratory  organs  are  the  more 
active  in  cold,  the  kidneys  in  temperate,  the  liver  and 
bowels  in  hot  climates.  It  has  been  shown  that  the 
urea,  the  chlorides,  and  the  other  constituents  of  urine 
decrease  as  the  air  rises  in  temperature  above  49°  F. 
("  Parkes  on  the  Urine,"  p.  95.)    On  the  other  hand,  it 


122  bright' S   DISEASE. 

is  believed — a  belief  wMch  is  consistent  with  much  of 
oar  knowledge — that  the  urea  lessens  also  with  severe 
cold."     ("Philosophical  Transactions,"  1861.) 

In  the  majority  of  cases  I  have  seen  I  have  been 
unable  to  assign  any  cause  unless  that  of  atmospheric 
influences,  but  as  a  rule  the  patients  were  not  able  to 
refer  the  beginning  of  their  malaise  to  taking  cold.  The 
following  instance  of  chronic  interstitial  nephritis  being 
produced  by  cold  is,  I  think,  clear  enough  :  In  March, 
1882,  a  physician  consulted  me.  I  found  the  urine 
at  each  of  several  examinations  to  show  the  existence 
of  chronic  interstitial  nephritis  with  cirrhosis.  Heart 
somewhat  hypertrophied.  The  history  was  that  while 
a  medical  student  in  Berlin  he  had  attended,  in  De- 
cember, 1879,  on  an  intensely  cold  night,  a  student's 
ball.  He  returned  to  his  lodgings  at  3  o'clock  a.m.  His 
room  was  very  cold,  and  he  suffered  for  want  of  suffi- 
cient bed  covering.  For  several  daj^s  after  he  experi- 
enced a  sensation  of  general  dulness  and  aching,  but 
recovered,  only  in  a  few  weeks  after  to  find  his  strength 
somewhat  impaired.  I  will  not  give  the  whole  details 
of  his  illness,  but  he  lost  strength  and  suffered  from 
many  of  the  symptoms  of  chronic  interstitial  nephri- 
tis. Previous  to  this  exposure  his  health  had  been 
excellent. 

Of  the  Heredity  of  Ii^terstitial  Nephritis. 

Except  as  an  accompaniment  of  transmitted  gout,  or 
of  some  other  inherited  disease,  as  tuberculosis  and  per- 
haps syphilis,  I  have  not  myself,  in  a  large  number  of 
cases,  seen  one  which  I  could  regard  as  inherited.  That 
the  tendency  to  it  may  be  transmitted  is  believed  by 
some  able  writers.  Tyson '  gives  an  account  of  two 
cases  which  came  under  his  own  observation,  occurring 

'  Bright's  Disease,  p.  166. 


inti:rstitial  nephritis — its  heredity.        123 

in  one  family,  the  relationship  being  such  as  to  leave  no 
reasonable  doubt  of  their  transmitted  nature.  These 
cases  seemed  to  be  interstitial  nephritis.  Dickinson 
presents  what  he  correctly  calls  "  a  remarkable  chapter 
in  the  history  of  disease,"  which  gives  an  account  of 
eighteen  cases  occurring  in  one  family  within  three  gen- 
erations : 

"The  first  generation  whereof  the  record  treats  con- 
sisted of  a  brother  and  four  sisters.  The  brother  died 
from  an  unknown  cause  at  the  age  of  thirty-four,  sud- 
denly, but  after  long  wasting.  Two  of  the  sisters  died 
at  the  ages  of  forty-nine  and  forty-eight  respectively, 
both  having  had  albuminuria  for  many  years. 

"  The  brother  left  two  sons  and  four  daughters.  One 
of  the  sons  died  at  the  age  of  twenty-six,  having  had 
albuminuria  from  the  age  of  twelve.  Of  the  daughters 
three  became  the  subjects  of  the  same  disease.     One, 

Lady ,  died  of  it,  with  more  or  less  oedema,  at  the 

age  of  thirty -nine,  having  had  it  since  she  was  sixteen. 
Two  others,  still  living,  at  the  ages  respectively  of 
thirty-eight  and  forty,  are  similarly  affected,  but  it  is 
not  known  at  what  date  they  became  so. 

"  The  third  generation  consists  of  the  six  children  of 

Lady ,  two  sons  and  four  daughters.     All  are  alive, 

but  five  are  the  subjects  of  albuminuria.  The  first-born, 
a  daughter,  now  twenty-one  years  of  age,  has  had  albu- 
minuria from  the  age  of  nine  months.  The  next,  a  son, 
now  twenty,  has  albuminous  urine,  but  it  is  not  known 
when  it  became  so.  The  third  appears  to  have  escaped 
hitherto.  The  fourth,  a  son,  now  sixteen,  has  had 
albuminuria  in  an  intermittent  form  from  early  boy- 
hood. The  fifth,  a  son,  now  fifteen,  has  had  albumi- 
nuria in  a  marked  form  for  two  years.  The  sixth  and 
last,  a  girl,  now  five  years  old,  has  passed  urine  which 
has  contained  decided  but  variable  amounts  of  albumin 
from  the  age  of  six  months." 


124  beight's  disease. 

Dr.  Joseph  Kidd  {Practitioner^  vol.  29,  No.  II.) 
gives  full  details  of  seven  cases  occurring  in  three  gen- 
erations, in  one  family,  many  members  of  which  he  had 
attended,  and  with  whose  constitutions  he  was  familiar. 
He  also  mentions  that  two  of  the  children  besides  of  one 
of  the  patients  were  subjects  of  Bright' s  disease.  Seven 
children  of  another  of  these  patients,  out  of  twelve,  died 
of  kidney  disease. 

Autopsies  were  made  in  two  of  the  cases  which  had 
proved  fatal.  A  careful  perusal  of  Dr.  Kidd's  interest- 
ing paper  justilies  my  concluding  that  part  of  these 
cases  were  chronic  interstitial  nephritis  and  part  chronic 
croupous  nephritis. 

The  possibility,  therefore,  of  the  hereditary  nature  of 
nephritis  should  not  be  excluded  from  the  etiology. 

Malarial  or  paludal  imisoning  is  considered  by  Dick- 
inson and  Bartels  a  very  common  cause  of  nephritis, 
particularly  the  interstitial  form.  Dickinson  believes 
that  long-continued  paroxysms  of  chill  may  induce 
renal  hypersemia.  My  own  experience  is  that  a  consid- 
erable proportion  of  the  cases  of  interstitial  nephritis 
which  I  have  seen  have  occurred  in  patients  who  have 
suffered  more  or  less  from  malarial  fevers,  and  I  believe 
these  to  be  sometimes  a  source  of  its  development.  I 
think  the  hepatic  congestion  accompanying  the  chills, 
the  latter  perhaps  producing  the  same  events  in  the  cir- 
culation of  the  kidneys,  may  induce  permanent  dila- 
tation and  hypersemia,  leading  to  general  inflamma- 
tion. 

Alcoholism. — I  have  not  been  able  to  trace  a  single 
case  of  interstitial  nephritis  to  the  direct  effect  of  over- 
use of  alcohol.  It  is  true  that  alcohol  in  inordinate 
quantities  can  be  made  to  produce  albuminuria.  When 
its  over-use  has  been  followed  by  the  development  of 
interstitial  nephritis,  I  believe  the  latter  to  be  secondary 
to  the  development  of  other  morbid  conditions. 


INTERSTITIAL   NEPIIEITIS — CAUSOLOGY.  125 

Bartels  says  that  out  of  all  tlie  numerous  cases  lie  liad 
seen,  onlj^  three  patients  had  used  stimulants  to  excess, 
by  far  the  greater  number  having  led  remarkably  ab- 
stemious lives. 

Very  extensive  and  searching  statistics,  collected  by 
Dickinson  from  cases  of  patients  who  had  died  from 
delirium  tremens,  showed  that  interstitial  nephritis 
existed  in  but  a  very  small  proportion  of  cases,  no 
greater  than  would  be  found  in  persons  dying  from 
other  causes.  It  was  found,  however,  that  in  the  post- 
mortems of  persons  who  had  been  addicted  to  the 
use  of  stimulants,  the  kidnej^s  were  often  enlarged, 
flabby,  and  congested.  (Probably  chronic  croupous  ne- 
jDhritis. — Author.) 

Cases  are  recorded,  however,  where  renal  contraction 
coexisted  with  hepatic  ciiThosis,  and  which  were,  like 
it,  due  to  alcoholic  poisoning. 

It  is  evident,  however,  that  a  substance  often  inimical 
to  the  human  system  may,  by  deteriorating  the  health, 
bring  about  renal  changes.  IN'evertheless,  I  believe  that 
many  pure  alcoholic  beverages  have  a  healthy  diuretic 
influence,  which  is  actually  beneflcial  to  the  integrity 
and  functional  activity  of  the  kidneys. 

Syphilis  may  be  a  cause  of  interstitial  nephritis.  At 
least  one  case  has  fallen  under  my  observation,  which 
was  under  my  care  from  the  moment  of  the  discovery  of 
the  infecting  chancre  to  the  time  of  death.  The  patient 
was  a  gentleman,  aged  twenty  years.  The  secondary 
symptoms  were  of  an  unusually  severe  and  intractable 
character,  iritis,  bad  ulceration  of  the  throat,  and  syph- 
ilitic rheumatism  all  occurring.  The  patient's  constitu- 
tion was  rather  poor,  and  after  the  specific  symptoms 
had  seemed  to  disappear  debility  continued,  which  was 
in  time  followed  by  albuminuria,  persistent  headaches, 
convulsions,  and  death.  The  autopsy  showed  embolism 
and  syphilitic  inflammation  of  the  middle  cerebral  ar- 


126  bright' S   DISEASE. 

tery,  and  interstitial  nephritis.  Death  occurred  six 
months  after  tlie  discovery  of  the  chancre. 

Gout  as  a  Cause  of  Interstitial  NepTiritis. — Tlie  co- 
existence of  interstitial  nephritis  with  gout  is  well 
known.  In  chronic  gout  the  former  almost  always 
exists — in  acute  paroxysms,  temporary  derangements  of 
the  kidneys,  with  albuminuria,  often  occur. 

In  gout,  as  in  interstitial  nephritis,  the  kidney  be- 
comes impermeable  to  uric  acid,  though  urea  is  secreted 
freely ;  but  above  all,  the  pathological  changes  in  the 
kidney  are  often  identical.  Garrod  considers  a  charac- 
teristic feature  of  the  gouty  kidney  to  be  depots  of 
urate  soda  at  the  summits  of  the  cones,  or  of  white 
striae  parallel  to  the  tubuli  uriniferi.  He  gives  minute 
details  of  the  appearance  of  many  gouty  kidneys  ;  and 
Charcot,  in  his  notes  to  the  French  translation  of  Gar- 
rod,'  considers  that  while  sometimes  the  gouty  kidney 
presents  the  features  of  croupous,  it  almost  always  has 
the  aspects  of  interstitial  nephritis. 

Though  albumin  be  present  in  the  majority  of  cases 
of  chronic  gout,  it  is  generally  in  small  amount.  Ac- 
cording to  Charcot :'  "As  regards  the  symptomatology, 
albuminous  nephritis,  when  dependent  upon  gout,  is  dis- 
tinguished especially  by  its  apparent  benignity  and  its 
slow  evolution.  Anasarca  and  oedema  are  often  want- 
ing ;  they  are  seldom  strongly  marked ;  frequently  the 
proportion  of  albumin  contained  in  the  urine  is  far  from 
considerable,"  etc.  "Even  these  phenomena  are  far 
from  being  constant.  However  it  may  be,  it  is  certain 
that  the  albuminous  nephritis  of  gouty  subjects  may, 
like  other  forms  of  the  disease,  be  accompanied  by  re- 
doubtable symptoms,  convulsive  or  comatose  uraemia  ; 
and  it  is  very  probable,  at  least,  that  a  large  number  of 

'  La  Goutte  sa  Nature,  son  Traitemeiit,  etc.,  par  A.  B.  Garrod,  Annote  par 
J.  M.  Charcot.     Paris,  1867.  ^  Note  to  Garrod. 


GOUT  AS   A   CAUSE   OF   INTERSTITIAL   NEPHRITIS.     127 

cerebral  accidents  attributed  to  migratory  or  misplaced 
gout,  are  simply  ureemic  accidents  secondary  to  the 
renal  affection  so  frequently  develoj)ed  under  the  influ- 
ence of  gout.  Dyspepsia  and  uraemic  diari-hoea,  inter- 
enceplialic  hemorrhage,  hypertrophy  of  the  heart,  are 
also  sometimes,  in  gouty  subjects,  the  consequences  of 
albuminous  nephritis." 

The  gouty  kidney  is  often,  indeed,  the  cirrhotic  kid- 
ney. Nevertheless,  in  acute  or  chronic  gout  an  imper- 
meability to  the  secretion  of  uric  acid  may  be  estab- 
lished, and  the  exudation  of  albumin  may  occur  with- 
out organic  disease,  as  a  transient  condition,  disappear- 
ing with  the  subsidence  of  the  gouty  attack.  According 
to  Garrod :  "The  kidneys  are  affected  in  gout  appar- 
ently in  the  initial  period  ;  they  certainly  are  when  the 
disease  has  become  chronic.  The  lesion  of  the  kidney 
is  at  first,  perhaps,  only  functional ;  later,  the  structure 
of  the  organ  is  modified."  It  is  shown  by  the  same  au- 
thor that  the  formation  of  large  quantities  of  uric  acid 
in  the  blood  is  not  necessarily  harmful,  as  is  evident 
from  what  occurs  in  birds,  where  nearly  all  the  nitro- 
genized  food  is  converted  into  uric  acid,  and  yet  the 
blood  is  found  to  be  free  from  it.  He  is  of  the  opinion 
that  the  alteration  of  the  blood,  which  results  from  the 
presence  of  urate  of  soda  in  excess,  is  probably  the 
cause  of  the  morbid  troubles  which  precede  the  access 
of  gout.  That  interstitial  nephritis  and  gout  coexist  is 
clear,  but  we  may  undoubtedly  believe  that  the  organ 
first  deranged  in  gout  is  sometimes  the  kidney,  the 
blood-poisoning,  swollen  joints,  and  gouty  symptoms 
proper  being  secondary.  I  have  met  with  cases,  how- 
ever, where  patients  suffered  from  severe  gouty  par- 
oxysms, but  whose  kidneys  were  free  from  functional 
or  organic  difficulties.  Such  cases  are,  however,  very 
exceptional. 

Lead  seems  so  to  affect  the  kidneys  as  to  interrupt 


128  bright' S   DISEASE. 

the  excretion  of  uric  acid.  It  is  the  opinion  of  Dr.  Gar- 
rod  that  saturnine  poisoning  will  produce  gout.  He  ar- 
rives at  this  conclusion  in  part  from  the  fact  that  at 
least  one^'ourth  of  all  the  gouty  patients  in  his  hospital 
had  been  affected  by  lead-poisoning.  He  had  observed 
that  painters  were  more  frequently  affected  by  gout 
than  any  other  class  of  workmen.  Charcot,  in  his  notes 
above  referred  to,  states  that  while  he  had  treated  one 
well-marked  case  of  gout  where  there  had  been  satur- 
nine poisoning,  and  no  heredity,  he  finds  it  difficult  to 
show  that  lead  in  itself,  without  the  aid  of  other  causes, 
can  produce  a  case  of  gout.  The  same  writer,  however, 
in  1879  ("Bright's  Disease  ")  states  that  G-arrod's  expe- 
rience has  been  established  by  his  own  observations,  and 
afterward  by  others.  "The  gout  of  saturnine  subjects," 
he  says,  "from  what  I  have  seen,  appears  to  differ  from 
ordinary  gout  only  in  the  greater  rapidity  of  evolution, 
the  abundance  of  topaceous  deposits,  and  the  necessary 
existence,  so  to  term  it,  of  renal  lesions." 

Garrod  and  Ollivier  cite  numerous  instances  in  which 
lead -poisoning  was  the  cause  of  nephritis,  and  Dickin- 
son states  that  the  records  of  St.  George's  Hospital, 
kept  by  him  for  seven  years,  showed  that  42  work- 
men having  to  do  with  lead,  as  painters,  plumbers, 
tin  workers,  and  compositors,  died  from  disease  or  ac- 
cident and  were  examined  at  the  hospital.  Of  this 
number  26  had  distinct  granular  degeneration  of  the 
kidneys,  disease  in  most  of  the  cases  having  been 
the  cause  of  death.  With  few  exceptions,  interstitial 
nephritis  is  the  only  form  which  lead-poisoning  pro- 
duces. Among  the  cases  above  recorded  there  was  but 
one  instance  of  the  occurrence  of  any  other  form,  and 
that  was  clearly  due  to  cold  and  exposure.  Lead  may 
also  produce  transient  albuminuria,  accompanied  by 
colic.  Allen  ("Encyclopedia  Materia  Medica  Pura") 
gives  many  cases  of  nephritic  derangement  and  disease 


INTERSTITIAL   NEPHRITIS   PRODUCED   BY   LEAD.      129 

produced  by  lead  ;  some  of  the  symptoms  clearly  indi- 
cate the  existence  of  acute  croupous  nephritis ;  as  for 
example,  "frequent  and  scanty  micturition,"  "sup- 
pression of  urine,"  "acid,  albuminous  urine,"  "numer- 
ous blood  corpuscles  and  epithelial  casts,"  "urine  dark 
brown,"  "specific  gravity,  1024."  These  phenomena 
clearly  show,  inasmuch  as  lead  is  excreted  by  and  fre- 
quently found  in  the  urine,  that  it  is  capable  of  bring- 
ing about  nephritis  (or  renal  congestion)  by  virtue  of  its 
toxic  or  irritating  properties  producing  local  irritation. 
Most  of  the  effects  of  lead-poisoning,  however,  quoted 
by  Allen,  indicated,  so  far  as  the  kidneys  were  con- 
cerned, the  existence  of  chronic  interstitial  nephritis. 
In  one  case  amaurosis  and  cerebral  symptoms  appeared, 
and  ceased  coinciden tally  with  the  appearance  and  ces- 
sation of  albumin.  The  most  minute  account  I  have 
met  with  of  the  condition  of  the  kidney  after  lead-poi- 
soning is  one  given  by  Allen  ("Encyclopedia  Materia 
Medica  Pura,"  article  on  "Plumbum,"  translated  from 
the  inaugural  thesis  of  F.  Terbutius,  Zurich,  1876),  the 
case  being  that  of  a  painter.  The  clinical  history  showed 
polj^uria,  albumin,  and  convulsions.  JSTo  anasarca.  The 
post-mortem  showed  "a  very  easy  separation  of  the 
suprarenal  capsules,  the  upper  surface  of  the  kidney 
granular,  the  parenchyma  very  moist,  the  cortical  sub- 
stance gray,  somewhat  reduced  in  size,  the  Malpighian 
corpuscles  not  distinct,  the  pyramids  gray.  Under  the 
microscope  the  kidneys  presented  an  exquisite  picture 
of  interstitial  nephritis  in  a  rather  early  stage  ;  the 
cortical  substances  especially  presented,  in  both  trans- 
verse and  vertical  sections,  great  cellular  hyperplasia 
and  increase  of  interstitial  connective  tissue,  though 
the  process  was  not  equally  diffused,  while  frequently 
the  whole  field  was  occupied  b}^  small  cells  of  connec- 
tive tissue  with  scarcely  a  trace  of  uriniferous  tubes ; 
other  sections  exhibited  the  tubules  of  normal  size  and 

9 


130  bright' S   DISEASE. 

configuration,  hut  separated  by  abnormally  broad  septa 
of  GonnectiTie  tissue ;  the  glomeruli  presented  varjdng 
characters,  some  normal,  others  atrophied  to  fibrillar 
Icnots  of  connective  tissue,  and  others  in  all  possible 
stages  of  degeneration.  The  substance  of  the  pj^ramids 
was  less  affected  than  the  cortical ;  the  growth  of  con- 
nective tissue  was  here  much  less  pronounced  and  in 
many  places  was  not  noticed  at  all ;  the  tubes  were  for 
the  most  part  denuded  of  epithelium.  The  small  arter- 
ies of  the  kidney  showed  no  remarkable  change  ;  in  the 
transverse  section  was  seen  a  very  broad  zone  of  con- 
nective tissue ;  hyperplasia,  thickening  of  the  walls, 
and  contraction  of  the  calibre  of  the  vessels  were  not 
noticed.  The  intertubular  capillaries  in  both  the  corti- 
cal and  tubular  portions  of  the  kidney  were  excessively 
filled ;  in  the  latter  there  were  numerous  spots  of  hemor- 
rhages into  the  urinary  canals,  and  here  and  there  the 
cavities  of  the  urinary  canals  were  found  stopjDed  by 
old  plugs  and  by  some  calcareous  concretions.  The 
liver  showed  analogous  changes  of  hyperplasia  of  con- 
nective tissue,  in  some  places  even  tubercular  nodes  of 
connective  tissue  growth.  The  heart  showed  inflamma- 
tory connective  tissue  growth,  with  chronic  myocardi- 
tis. In  some  places  very  broad  septa  of  small-celled 
connective  tissue  was  formed  between  single  muscular 
fibrillse." 

In  lead-poisoning  it  is  not  likely  that  an  excess  of 
uric  acid  is  formed,  but  the  kidney  becomes  incapable 
of  excreting  it ;  hence,  according  to  Garrod,  it  is  to  be 
found  in  the  blood  in  nearly  every  case  of  lead  poison- 
ing, while  the  urine  contains  but  very  little  of  it.  The 
salts  of  lead,  uric  acid,  and  the  salts  of  soda  in  lead- 
poisoning,  and  the  two  latter  in  interstitial  nephritis 
and  in  gout,  are  often  found  in  the  interstitial  tissue  of 
the  kidney.  In  the  granular  kidney  of  gout  it  is  not 
uncommon  to  find  the  apex  of  the  pyramidal  bodies 


INTERSTITIAL   NEPHEITIS — CATISOLOGY.  131 

studded  with  ciystals  of  uric  acid.  Uric  acid  is  usually 
found  in  excess  in  the  blood  in  chronic  interstitial  ne- 
phritis either  from  over-formation  or  non-elimination,  and 
may  therefore  be  regarded  as  a  constant  accompaniment 
of  the  gouty  cirrhotic  kidney.  Urea  may,  however,  be 
freely  excreted  in  gout  and  lead-poisoning,  when  uric 
acid  cannot.  Lead  will  sometimes  develop  gout  in  cases 
where  the  ordinary  causes,  as  high  living,  wines,  want 
of  exercise,  and  inherited  tendencies,  do  not  exist.  In 
searching  for  the  various  causes  of  nephritis,  we  are  not 
always  to  look  for  cases  of  lead-poisoning  from  the  ab- 
sorption of  large  quantities  of  lead.  Certain  elements 
in  drinking-water,  as  oxygen  and  organic  matters,  the 
nitrates  and  chlorides,  make  lead  very  soluble,  and  suf- 
ficient may  be  washed  from  lead-pipes  to  make  it  poi- 
sonous. Small  quantities,  -^  to  ^V  grain  to  the  gallon, 
may,  according  to  Kinger,  produce  lead-poisoning  in 
some  people. 

PregnanQy. — That  this  condition,  when  the  gravid 
uterus  becomes  large  enough  to  obstruct  the  renal  cir- 
culation, may  sometimes  induce  nephritis,  may  be  ad- 
mitted. I  believe  it  to  be  croupous  nephritis  which  is 
usually  produced,  and  I  have,  therefore,  spoken  more 
fully  in  regard  to  this  in  the  chapter  upon  the  etiology 
of  that  form. 

Cystitis. — Next  to  cold,  cystitis,  acute  or  chronic,  is 
the  most  frequent  cause  of  interstitial  nephritis.  It  is 
almost  impossible  to  find  a  severe  case  of  cystitis  in 
which  the  kidneys  do  not  become  at  least  slightly,  and 
often  badly,  involved.  Epithelia  from  the  tubules  may 
almost  always  be  found  in  the  urine,  sometimes  also 
from  the  pelvis.  As  casts  are  not  common  in  intersti- 
tial nephritis,  of  course  we  are  not  likely  to  find  them  in 
these  cases.  So  intimate  is  the  causology  between  the 
cystitis  and  nephritis  that  the  latter  usually  subsides 
pari  passu  with  the  former. 


132  beight's  disease. 

Yal'\)ulaT  disease  of  the  heart  may  produce  intersti- 
tial nephritis,  resulting  from  long  continuous  venous 
congestion.  I  cannot  agree  with  those  authors  who  do 
not  regard  the  alterations  in  the  kidney  thus  produced 
as  the  product  of  inflammation.  We  find  the  same 
changes  in  connective  tissue  and  epithelia  as  in  inter- 
stitial nephritis,  the  differences  being  simply  those  of 
degree.  The  so-called  cyanotic  kidney  is  not  a  kidney 
affected  in  an  anomalous  manner,  "blue  and  tough," 
but  presents  all  the  features  of  interstitial  nephritis. 
In  a  large  number  of  autopsies  of  people  who  died  from 
valvular  disease  of  the  heart,  interstitial  nephritis  was 
found  in  nearly  one-half  the  cases  ;  the  surface  of  the 
kidney  was  sometimes  smooth,  but  oftener  granular. 
It  is  difficult  to  explain,  however,  why  venous  conges- 
tion from  valvular  disease  should  produce  interstitial 
nephritis,  and  congestion  of  the  kidney  in  pregnancy, 
from  pressure  on  the  veins,  should  produce  croupous 
nephritis.  Other  causes,  however,  than  venous  obstruc- 
tion, of  which  we  are  ignorant,  may  enter  into  the  de- 
velopment of  the  nephritis  of  pregnancy,  while  many 
cases  originate  in  causes  quite  independent  of  preg- 
nancy. 

CouESE  AND  Symptoms. 

There  is  no  other  organic  disease  which  lingers  so 
slowly  in  its  apparent  development  as  this  form  of  ne- 
phritis. It  seems  to  burst  into  existence  in  full  panoply, 
as  Minerva  from  the  head  of  Jupiter.  Apparently  good 
health  may  even  be  enjoyed  after  its  development. 

Ursemic  headaches  may  even  occur,  without  albumin 
ever  being  found  in  the  urine.  If  I  were  to  attempt  to 
designate  any  one  condition  as  most  likely  to  be  present 
in  the  early  but  fully  developed  stages  of  interstitial 
nephritis,  I  should  mention  loss  of  strength  as  that  one, 
headaches,  derangements  of  digestion,  as  anorexia,  nau- 


INTEESTITIAL  IS-EPHRITIS — COURSE  AND  SYMPTOMS.       133 

sea,  bilious  derangements,  flatulence,  etc.,  being  next  in 
frequency.  That  interstitial  nepliritis  may  for  a  long 
time  exist,  and  even  produce  cirrhosis,  without  albumin 
ever  existing  in  interstitial  nepliritis,  I  have  endeavored 
to  show  in  Chapter  XIX. 

In  the  majority  of  cases  of  sufficient  gramty  to  im- 
pair tlie  liealtJi,  liowever^  albumin  is  found  at  least  at 
intervals.  The  urinary  examinations  in  suspected  cases 
should,  therefore,  be  frequent,  until  either  albumin  is 
found,  or  the  physician  is  assured  that  it  does  not  exist. 

Amongst  other  symptoms  an  unhealthy  look  is  often 
developed,  sometimes  anaemic,  and  usually  pallid.  A 
frequent  desire  to  urinate,  the  urine  being  passed  in 
considerable  quantities,  soon  becomes  noticeable.  The 
patient  often  is  obliged  to  rise  several  times  in  the  night 
to  urinate.  The  urine  is  generally  pale,  and  of  low 
specific  gravity.  The  quantity  of  albumin  is  usually 
small,  and  often  in  the  fully  developed  stage  is  tempo- 
rarily absent,  a  circumstance  well  calculated  to  mislead 
the  physician. 

Bartels,  relative  to  this  point,  says:  "Albuminuria 
is  no  constant  symptom  in  this  affection,"  and  also 
states  that  he  has  repeatedly  witnessed  its  temporary 
absence.  This  transient  absence  is,  however,  well 
known. 

The  urine  is  clear,  sometimes  pellucid,  often  soapy 
looking ;  its  specific  gravity  is  usually  low  (1000  to 
1016).  The  amount  of  urea,  according  to  Dickinson,  is 
very  much  reduced  ;  according  to  Bartels  and  Charcot, 
who  are  undoubtedly  correct,  it  is  not  reduced.  The 
fact  is  that,  though  it  is  diminished  in  a  given  quantity 
of  urine,  yet  an  abnormal  quantity  being  voided,  the 
normal  percentage  of  urea  is  voided  in  the  twenty- 
four  hours.  As  Charcot  remarks,  this  is  peculiar,  be- 
cause in  this  form  it  is  that  ursemic  accidents  are  most 
common. 


134  beight's  disease. 

The  quantity  of  uric  acid  is  somewhat  reduced  from 
the  first,  and  in  the  advanced  stages  is  almost  entirely 
absent. 

Casts  are  much  less  abundant  than  in  croupous  ne- 
phritis. Occasionally  blood  corpuscles  are  formed,  but 
only  when  there  is  acute  recurrence.  The  amount  of 
urine  voided  seems  to  depend  more  upon  the  amount 
of  cardiac  pressure  exerted  than  upon  any  other  direct 
affection  of  the  kidney. 

We  often  find,  when  the  kidney  is  dwindled  to  a  frac- 
tion of  its  normal  size,  that  urine  still  continues  to  be 
secreted  in  larger  quantities  than  in  health  ;  this  is  ow- 
ing to  the  hypertrophy  of  the  left  ventricle  being  com- 
pensatory to  the  wasted  kidney.  Though  many  of  the 
corpora  Malpighiana  are  destroyed,  those  which  remain 
have  pushed  into  them  an  increased  quantity  of  blood, 
and  this,  with  such  an  amount  of  arterial  pressure  as  to 
favor  the  transudation  of  the  aqueous  elements,  pro- 
duces a  large  aqueous  secretion.  This  compensatory 
action  on  the  part  of  the  heart  prevents  the  accumula- 
tion of  fluid  in  the  cellular  tissue  and  cavities,  and  con- 
sequently dropsical  affections  and  oedema  are  very  rare 
in  this  form  of  nephritis.  So  long  as  the  heart's  action 
remains  vigorous  the  depurative  action  of  tlie  kidney 
may  continue.  As  soon,  however,  as  the  power  of  the 
heart  is  from  any  cause  diminished,  scanty  and  concen- 
trated urine  results,  and  the  various  symptoms  of  re- 
tention, dropsy,  and  anasarca  are  not  slow  in  making 
their  appearance. 

Hemorrhagic  attacks  are  more  common  in  this  than 
in  any  other  form  of  nephritis.  They  take  place  from 
the  nose,  from  the  stomach,  and  within  the  cranial  cavity. 

In  111  cases  of  death  from  apoplexy,  occurring  in  St. 
George's  Hospital  and  in  the  practice  of  Mr.  Thomas 
Jones,  there  was  granular  degeneration  of  the  kidney  in 
55  cases  (Dickinson). 


INTEESTITIAL   NEPHRITIS — VAEIOUS   LESIONS.       135 

The  causes  of  these  hemorrhagic  tendencies  may  be 
found,  mainly,  in  the  greatly  increased  arterial  pressure, 
the  blood  wanting  in  coagulability,  and  in  the  athero- 
matous condition  of  the  arteries.  Charcot  considers 
the  existence  of  miliary  aneurisms  to  be  a  common  cause 
of  cerebral  hemorrhage,  and  he  has  shown  their  exist- 
ence in  intra- cephalic  hemorrhages  in  persons  suffering 
from  interstitial  nephritis. 

Among  the  most  frequent  pathological  lesions  which 
occur  are : 

First. — Albuminous  retinitis,  showing  itself  in  au- 
topsy, according  to  Charcot,  by  white  plaques,  traversed 
by  small  hemorrhagic  strige  in  the  retina. 

Second. — A  considerable  thickening  of  the  skull 
cap. 

TJiird. — Chronic  endocarditis,  or  arterial  atheroma; 
the  arteries  may  also  undergo  muscular  thickening, 
muscular  degeneration,  and  thickening  of  the  fibroid 
sheath. 

The  lesion,  however,  most  constantly  present,  and  al- 
most pathognomonic  of  this  disease,  is  the  hypertrophy 
of  the  left  ventricle,  generally  without  valvular  lesion. 
That  this  exists  almost  always,  in  advanced  stages,  is 
generally  conceded.  Bright  recognized  the  coincidence 
of  hypertrophy  with  renal  atrophy ;  Bartels  says  he 
has  never  found  a  case  where  it  did  not  exist  ;  while 
Dickinson  says  he  has  never  found  it  in  parenchymatous 
nephritis.  Grainger- Stewart  asserts  that  it  is  never  com- 
pletely absent  at  an  advanced  stage. 

This  rule  of  the  existence  of  hypertrophy,  while  it 
may  hasten  a  fatal  termination  of  the  disease,  in  most 
cases,  as  we  shall  see,  prolongs  life. 

Space  will  not  permit  me  to  show,  as  might  easily 
be  done,  the  incorrectness  of  the  theories  of  Gull  and 
Sutton  relative  to  hypertrophy  of  the  heart  in  intersti- 
tial nephritis.     According  to  these  writers,  the  cardiac 


136  beight's  disease. 

changes  are  not  consequent  upon,  but  coeval  with,  the 
renal ;  the  vascular  system  and  kidneys  taking  part 
simultaneously  in  a  deterioration  common  to  the  whole 
body,  and  allied  to  senile  decay. 

Undoubtedly  the  cause  of  the  cardiac  hypertrophy, 
in  the  great  majority  of  cases,  is  the  renal  change. 

It  is  likely,  of  course,  that  a  dyscrasia  may  induce, 
simultaneously,  changes  in  the  interstitial  tissue  and  in 
the  heart,  and  this  is  no  doubt  sometimes  the  case. 
Dickinson  believes  that  the  cardiac  and  vascular  changes 
are  due  to  the  labor  imposed  upon  them  of  propelling 
contaminated  and  impure  blood.  This  theory  is  hardly 
worthy  a  practical  observer.  In  parenchymatous  ne- 
phritis, especially  when  accompanying  or  resulting  from 
suppurative  processes,  the  blood  is  equally,  contami- 
nated, and  should  be  more  so.  Here,  however,  hyper- 
trophy of  the  heart  is  seldom  found. 

Certainly,  as  evinced  by  the  tense,  hard,  and  often 
full  pulse,  the  arterial  pressure  is  much  increased. 
Dickinson  says  the  overfulness  of  the  arteries  is  the 
cause  both  of  the  changes  in  their  coats  and  of  the  ven- 
tricular hypertrophy. 

But  what  causes  the  fulness  of  the  arteries  %  We 
must  look  further  than  this.  Traube  was  the  first  to 
attribute  hypertrophy  of  the  heart  to  the  increase  of 
arterial  tension,  resulting  from  the  obstruction  and  ob- 
literation of  arterial  branches  in  the  kidney  and  Malpi- 
ghian  tufts;  in  the  language  of  Bartels,  "placing  the 
consequences  of  renal  contraction  in  the  same  category 
with  the  results  which  deficiency  of  the  mitral  valve 
exercises  upon  the  right  chamber  of  the  heart." 

The  heart,  it  is  important  to  add,  usually  becomes 
hypertroj)hied  in  the  secondary  contraction  of  the  con- 
tracted kidney,  which  takes  place  after  parenchymatous 
nephritis. 

Probably  Traube's  explanation,  as  might  be  shown  by 


HYPERTROPHY   OP   THE   HEART.  137 

numerous  reasons,  is  the  correct  one  ;  although  a  theory 
embodied  in  a  paper  published  b}'"  Drs.  DaCosta  and 
Longstreth '  merits  consideration.  It  is  to  the  effect  that 
in  the  contracting  kidney,  more  especially,  there  are, 
more  or  less  constant,  "  certain  changes  in  the  nervous 
renal  ganglia  which  consist  essentially  in  a  hyperplasia 
of  the  connective  tissue  and  a  fatty  degeneration  of  the 
nerve-cells."  They  think  this  "is  the  cause  of  the  re- 
nal malady,  and  precedes  the  degenerative  changes;" 
also  that  they  "  do  not  think  the  heart  hyxDertrophies, 
because  of  the  opposition  the  passage  of  blood  meets 
in  the  renal  circulation  ;  but  that  it  is  to  be  traced  to  a 
central  origin,  in  one  case  to  the  cardiac  ganglia  and  in 
the  other  to  the  renal."  The  existence  of  these  changes 
has  been  confirmed  by  Dr.  Saundby  {British  Medical 
Journal^  January  13,  1883),  though  he  regards  the  pro- 
cess to  be  one  of  pigmentary  metamorphosis  merely. 
The  assumption,  however,  that  these  changes  are  the 
cause  of  contracted  kidney  is  unjustifiable.  Certainly, 
inflammation  of  a  sufficiently  severe  character  to  pro- 
duce hyperplasia,  etc.,  could  easily  bring  about  changes 
in  the  nerves. 

In  addition  to  the  disturbances  of  vision  of  a  fixed 
character  produced  by  albuminous  retinitis,  ursemic  am- 
aurosis sometimes  occurs ;  the  blindness  is  character- 
ized, according  to  Charcot,  by  those  disturbances  of 
vision  which  do  not  during  life  manifest  themselves  by 
any  alteration  appreciable  by  the  ophthalmoscope.  This 
condition  is  known  as  ursemic  amaurosis. 

Retinal  changes  in  severe  cases  of  interstitial  nephri- 
tis are  not  common.  For  descriptions  and  diagnosis 
of  these  changes  I  must  refer  the  reader  to  known  au- 
thorities on  these  subjects,  and  may  here  mention  the 
paper  of  Dr.  William  F.  Norris  in  "Tyson  on  Bright' s 

'  American  Journal  of  the  Medical  Sciences,  vol.  Ixxix.,  1880. 


138  bright' S   DISEASE. 

Disease;"  and  also  subjoin  the  list  of  authors  recom- 
mended by  him  : 

AUbutt :  "  Use  of  the  Ophthalmoscope  in  Diseases  of 
the  Nervous  System  and  of  the  Kidneys."   London,  1871. 

Leber  :  in  Graf e  and  Saemisch'  s  ' '  Handbuch  der  Au- 
genheilkunde,"  vol.  v.     Leipzig,  1877. 

Forster  :  in  Grafe and Saemisch's  "Handbuch der  Au- 
genheilkunde,"  vol.  vii.     Leipzig,  1877. 

Gov^^ers  :  "A  Manual  and  Atlas  of  Medical  OjDhthal- 
moscopy."     London,  1879. 

Liebreich:  "  Atlas  d' Ophthalmoscopie."    Paris,  1863. 

Jaeger:  "Ophthalmoscopischer  Hand  Atlas."  Vfein, 
1869. 

Magnus  :  ' '  Die  Albuminurie  in  ihren  Ophthalmoscop- 
ischen  Erscheinungen."     Leipzig,  1873. 

Although  the  quantity  of  excreted  urea  is  greater  than 
in  croupous  nephritis,  and  is  indeed  almost  normal, 
ursemic  accidents  are  more  frequent.  Charcot  explains 
this  by  the  fact  that  the  subjects  of  interstitial  nephritis 
are  generally  well  nourished,  forming  an  abundance  of 
urea,  and  that  this  normal  elimination  of  urea  is  due  to 
a  permanent  increase  of  arterial  tension.  The  heart  be- 
comes hypertrophied,  and  the  water  is  excreted  in  nor- 
mal amount,  carrying  with  it  a  sufficient  quantity  of  urea. 
This  secretion  is,  however,  unstable  ;  sudden  lowering  of 
the  heart's  action  from  any  cause,  moral  or  physical, 
may  diminish  the  amount  excreted.  In  such  cases,  and 
if  in  time  the  organic  changes  in  the  kidney  become 
so  extensive  as  greatly  to  impair  the  renal  functions, 
ursemic  poisoning,  the  usual  cause  of  death  in  this  form 
of  nephritis,  results. 

Dropsy  does  not  occur,  though  there  is  often  oedema 
of  the  eyelids,  and  sometimes  slight  oedema  of  the  feet. 

Headache  of  a  persistent  and  violent  character  is  com- 
mon. This  is  due  to  blood-pressure  and  to  the  reten- 
tion of  morbid  elements. 


INTERSTITIAL   NEPHRITIS — ACCIDENTS.  139 

Rheumatic  pains,  very  intractable,  occur.  Deep- 
seated,  violent  pains  in  the  limbs  are  not  uncommon. 
Spasms  and  convulsions  are  common,  as  are  also  dis- 
turbances of  the  nervous  system  and  the  morale.  The 
most  amiable  and  sanguine  dispositions  become  mor- 
bidly depressed,  peevish,  suspicious,  and  impatient, 
sometimes  hyper-excitation  of  the  nervous  system  al- 
most maniacal  in  its  character,  and  suicidal  tendencies 
being  developed. 

Coma  is  more  likely  to  occur  in  this  form  of  Bright' s 
disease  than  epileptiform  seizure.  Apathy  and  semi-tor- 
pidity of  the  physical  and  mental  power  are  common  in 
advanced  stages. 

Prurigo  and  a  urinous  smell  are  often  met  with.  The 
latter,  accompanied  by  partial  anuria,  generally  indicates 
speedy  dissolution.  (Edema  of  the  lungs  often  brings 
about  a  fatal  termination. 

In  some  cases  the  skin  is  covered  with  a  crystalline 
coating  of  urea. 

The  visceral  inflammation  most  frequently  met  with 
in  interstitial  nephritis  are  bronchitis,  pericarditis  with- 
out endocarditis,  pneumonia,  and  endocarditis  ;  the  fre- 
quency of  these  occurring  in  the  order  above  named. 
Ulceration  of  some  part  of  the  mucous  membrane  of  the 
bowels  may  also  occur. 

As  a  matter  of  course,  affections  of  the  digestive  sys- 
tem are  numerous,  and  often  distressing  ;  the  vomiting 
in  some  cases  cannot  be  controlled.  Diarrhcea  occurs 
occasionally. 

As  the  disease  advances  the  sexual  instinct  and  power 
often  become  diminished  or  are  lost. 


140  bright' S   DISEASE. 

Diagnosis. 

This  is  usually  easy.  The  chief  diagnostic  signs  have 
already  been  enumerated  in  the  chapter  on  "Chronic 
Croupous  N'ephritis." 

As  it  has  been  shown  in  a  former  chapter  that  the 
presence  of  albumin  in  urine  is  by  no  means  indicative 
of  nephritis,  it  is  equally  true  that  nephritis,  and  even 
cirrhosis,  may  exist  without  albuminuria.  I  cannot 
better  demonstrate  this  than  by  subjoining  in  the  next 
chapter  a  portion  of  a  paper  contributed  by  me  to  the 
New  YorJc  Medical  Journal,  November,  1883,  entitled 
"  On  the  Exclusion  of  Albuminuria  in  the  Diagnosis  of 
Interstitial  Nephritis,  and  on  the  Existence  of  Cirrhosis 
without  Albuminuria." 


CHAPTER  XIX. 

FEPHRITIS   WITHOUT    ALBUMINURIA. 

It  is  unquestionable  that  albumin  will  always  be  an  im- 
portant factor  in  the  recognition  of  those  forms  of  ne- 
phritis ordinaril}^  known  as  Bright' s  disease.  I  say  those 
forms  of  inflammation  commonly  known  as  Bright' s 
disease,  because  grave  inflammation  may  exist,  produ- 
cing even  cirrhosis,  without  the  development  of  one 
of  the  conditions,  namely,  albuminuria,  which  Bright 
seemed  to  consider  pathognomonic  of  the  disease  which 
bears  his  honored  name. 

The  fact  is,  however,  that  in  chronic  nephritis,  especially 
in  the  interstitial,  the  appearance  of  albumin  is  often  pre- 
ceded for  a  considerable,  and  even  for  a  very  long  time, 
by  morbific  changes  in  the  kidney  which  are  not  recog- 
nized until  the  appearance  of  albumin.  Indeed,  nephri- 
tis may  exist  to  such  an  extent  as  to  produce  even  cir- 
rhosis without  albumin  exier  making  its  appearance  in 
the  urine.  Bartels '  gives  the  details  of  the  case  of  a 
patient  in  the  hospital  at  Kiel,  fifty-six  years  of  age, 
who  died  five  weeks  after  admission,  and  whose  urine 
was  submitted  to  frequent  examinations  without  albu- 
min being  found.  The  most  prominent  symptoms  pre- 
vious to  and  after  his  admission  were  loss  of  strength, 
insensibility,  apparently  fainting,  the  extraordinarily 
low  temperature  (83°  Fahr.)  existing  most  of  the  time, 
and  delirium.  A  few  days  before  his  death  he  was  vac- 
cinated, six  vaccine  pustules  being  formed,  and  two  days 

'  Von  Ziemssen's  Cyclopaedia  of  Mediciue,  vol.  xv.,  p.  440. 


142  BKTGIIT  S    DISEASE. 

before  his  death  the  temperature  reached  106''  Fahr. 
During  the  high  fever  of  vaccination  small  amounts  of 
albumin  were  found.  This  substance  is,  however,  pres- 
ent in  the  urine  in  many  cases  of  fever  attaining  a  high 
temperature.  The  autopsy  showed  both  kidnej^s  greatly 
atrophied,  cirrhotic,  granular,  retracted,  and  containing 
large  and  small  cysts.  The  heart  was  greatly  hypertro- 
phied.  There  were  marks  of  severe  cystitis  and  strict- 
ure of  the  urethra.  Tlie  urine  in  tJie  bladder  was  not  al- 
buminous.    There  was  no  cedema  of  the  cellular  tissue. 

Bartels  gives  this  case  as  the  only  one  which  had 
come  under  his  obsernation  in  which  albumin  was  en- 
tirely absent  from  the  urine  throughout,  and  where, 
"  therefore^^  the  renal  malady  was  not  recognized  dur- 
ing the  patient's  lifetime.  The  "therefore"  is  ben  tro- 
vato,  but  illustrates  the  truth  of  my  assertions  concern- 
ing the  too  great  reliance  of  practitioners  upon  the 
presence  of  albumin  as  a  means  of  recognizing  inter- 
stitial (catarrhal)  nephritis.  As  the  patient  had  been 
under  observation  for  only  five  weeks  before  his  death, 
and  as  the  nephritis  had  evidently  had  a  long  existence, 
it  is  manifestly  unjustifiable  to  assume  that  at  no  period 
of  the  disease  previous  to  the  admission  of  the  patient 
to  the  hospital  could  albumin  have  been  found.  As  it  is, 
however,  the  case  is  illustrative. 

Dr.  Seller,  of  Philadelphia,  states  that  of  a  large 
number  of  kidneys  he  has  examined  after  death  from 
various  causes,  he  has  not  found  more  than  three  per 
cent,  perfectly  healthy ;  and  other  pathologists,  who 
have  made  a  large  number  of  autopsies  of  subjects  who 
died  a  natural  death,  have  found  it  altogether  the  ex- 
ception for  the  condition  of  the  kidneys  to  be  perfectly 
normal.  The  deflections  from  health  in  many  of  these 
instances  were  no  doubt  small — probably  so  slight  that 
only  repeated  and  accurate  microscopic  examinations 
would  have  discovered  anything  abnormal  in  the  urine 


ISTEPHRITIS    WITHOUT    ALBUMIXURIA.  143 

of  the  patients.  Still,  I  maintain  that  in  catairlial  (in- 
terstitial) nephritis,  at  all  events,  the  form  designated 
by  Charcot  '"primitive  chronic  interstitial  nephritis.'' 
the  albumin  may  not  make  its  appearance  until  an 
advanced  and  hopeless  stage  of  the  disease  has  been 
reached. 

To  rely  upon  albumin  solely  as  a  means  of  determin- 
ing the  existence  or  non-existence  of  nepbritis  is  to  rely 
upon  an  ignis  fatuus.  It  is  at  best  but  a  coarse  and 
primitive  test  of  its  presence,  insufficient  in  itself  and 
unsatisfactory  in  comparison  with  more  searching  and 
absolutely  accurate  means  of  diagnosis.  Regarded  as 
supplementary  to,  and  used  in  conjunction  with,  other 
physical  means  of  diagnosis,  and  with  rational  and  clini- 
cal symptoms,  albumin  becomes,  however,  when  it  is 
discovered,  of  the  greatest  value.  Its  persistent  absence 
also,  even  when  the  microscopic  indications  of  nephritis 
are  present,  is  of  importance  in  aiding  to  determine  how 
extensive  is  the  lesion  of  the  kidney,  and,  to  some  ex- 
tent, what  parts  are  free  from  disease. 

In  a  recent  monograph  Charcot '  shows,  I  think,  nota- 
bly from  experiments  made  by  Nussbaum,  Overbeck, 
and  Heidenhain  :  1.  That  the  elimination  of  albumin, 
whether  of  the  serum  or  globulin  of  the  blood,  by  the 
kidneys,  as  a  pathological  condition,  or  of  the  varieties 
of  albumin  foreign  to  the  constitution  of  the  blood,  as 
the  white  of  %%^^  is  not  in  any  way  a  simple  matter  of 
filtration.  He  shows  that  ac[ueous  filtration  is  performed 
or  takes  place  in  the  glomerulus  by  means  of  its  capil- 
laries, whose  thin  walls,  as  it  were,  bare  in  the  capsule 
of  Bowman,  from  which  it  is  separated  only  by  a  thin 
epithelial  lamella,  perform  the  function  of  filtration  of 
the  water  at  the  expense  of  the  blood  plasma.  2.  That 
the  filtration  of  the  water  is  a  vital  process,  and  that 

'  Charcot :  Lemons  pathogeniques  de  ralbuminurie.     Paris,  1881. 


144  beight's  disease. 

certain  conditions  and  interruptions  of  the  blood-supply 
of  tlie  glomerulus  bring  about  anoxaemia  (anoxemie  ') 
of  the  epithelia  of  the  glomerulus,  which  interrupts  its 
functions.  3.  That  the  epithelia  of  the  glomerulus 
play  an  important  part  in  the  secretion  of  glucose,  salts, 
and  albumin.  4.  That  the  labyrinth  or  canals  do  not 
in  any  way  participate  in  the  secretion  of  albumin. 

Admitting  the  correctness  of  these  conclusions,  it  is 
easy  to  see  that  in  an  inflammatory  condition  of  the  kid- 
ney, as  in  cloudy  swelling  of  the  epithelia  of  the  tubules 
and  in  hyperplasia  of  the  connective  tissue,  the  glome- 
rulus may  for  a  long  time,  and  when  the  inflammation 
is  mild,  remain  unaffected.  The  conclusion  that  noth- 
ing is  the  matter  with  the  kidneys  because  after  several 
examinations  of  the  urine  no  albumin  is  found,  is  some- 
times literally  a  fatal  error  ;  yet  how  numerous  are  the 
instances  where,  after  the  orthodox  one  or  two  chemical 
examinations,  the  kidneys  are  pronounced  "  healthy  !  " 
These  false  conclusions  are  not  reached,  even  as  a  rule, 
by  the  illiterate  and  uneducated  practitioner  exclu- 
sively, but  by  medical  men  who  are  considered  emi- 
nent. I  cite  the  following  instance,  not  in  a  spirit 
depreciatory  of  an  honored  and  useful  hospital,  but  to 
show  how  often,  if  such  a  case  can  occur  in  an  institu- 
tion whose  medical  staff  belong  to  the  better-educated 
class  of  physicians,  cases  of  non-recognized  nephritis 
must  occur  in  practice  generally,  and  how  many  patients 
march  toward  their  graves,  their  medical  advisers  all  un- 
conscious of  the  teterrhna  causa  of  broken  health  until 
physical  helplessness,  convulsions,  apoplexy,  or  death 
makes  at  last  a  diagnosis  for  the  perplexed  practi- 
tioner. 

While  visiting  another  hospital,  in  1879,  as  one  of  the  medical  stajBf, 
there  was  admitted,  May  9th,  a  young  man,  aged  twenty-three.     He 

'  Anoxmmia,  a  deoxygenated  state  of  the  blood. 


NEPHRITIS   WITHOUT  ALBUMINURIA.  145 

had  been  for  two  months  an  innaate  of  the  hospital  first  refen-ed  to, 
from  which  he  had  been  discharged  a  week  or  two  before,  as  being  no 
longer  ill  enough  to  require  medical  treatment.  He  understood  that 
the  physicians  of  the  hospital  had  pronounced  his  illness  to  be  some 
malarial  trouble,  with  debility.  He  had  not  been  confined  to  his  bed. 
His  sallow  appearance  and  anaemic  condition  easily  suggested  the  ex- 
istence of  some  such  disease. 

I  was  led,  however,  to  suspect  the  existence  of  interstitial  nephritis. 
There  were  persistent  headaches,  great  exhaustion,  and  slight  nausea. 
There  was  hypertroijhy  of  the  left  ventricle,  but  no  oedema  nor  ana- 
sarca. An  examination  of  the  urine  showed  the  existence  of  albumin, 
oxalate  of  lime,  pus,  kidney  epithelia,  and  hyaline  casts.  Eepeated 
examinations  gave  the  same  result.  The  urine  was  abundant.  My 
diagnosis  was  entered  as  chronic  interstitial  nephritis.  Eight  days 
after  his  admission  he  was  seized  with  epileptiform  convulsions. 
These  recurred  several  times,  a  settled  condition  of  coma  being  at  last 
established,  and  he  died  May  27th.  His  relatives  would  not  allow  a 
j)Ost-mortem  examination  to  be  made.  Being  curious  to  know  what 
the  diagnosis  of  his  case  had  been  at  the  hospital  where  he  had  been 
so  long,  I  inquired  of  the  house  physician,  and  was  informed  that  it 
had  been  considered  a  case  of  "  anaemia  and  debility."  At  all  events, 
it  had  not  been  entered  nor  treated  as  a  case  in  which  the  kidneys 
were  implicated.  He  stated  that  the  urine  was  examined  immediately 
after  his  admission,  and  that  no  albumin  was  found.  I  do  not  give 
the  name  of  the  hospital,  because  I  do  not  consider  that  the  purpose 
of  my  paper  would  be  subserved  by  so  doing.  The  case,  however,  is 
one  of  record. 

To  test  the  urine  simply  for  albumin,  and  that  only 
once  or  twice,  is  often  useless.  It  must  be  tested  re- 
peatedly ;  the  quantity,  specific  gravity,  and  chemical 
peculiarities  must  be  carefully  noted,  and,  most  of  all, 
the  phenomena  disclosed  hy  the  microscope  must  be 
considered. 

It  must  not,  however,  he  too  hastily  concluded  that 
albumin  is  not  present.  Its  existence  is  not  always 
shown  by  the  most  careful  testing  by  heat  and  nitric 
acid,  and  it  then  becomes  necessary  to  resort  to  more 
delicate  tests,  with  the  precautions  of  clarification,  etc., 
described  in  Chapter  IX.  It  is  perfectly  possible,  I  be- 
10 


146  bright' S   DISEASE. 

lieve,  by  these  tests  to  pronounce  positively  as  to 
the  presence  or  absence  of  albumin.  As  some  of  the 
tests  have  been,  until  recently,  but  little  employed,  it 
is  more  than  probable  that  in  some  of  the  reported 
cases  of  nephritis  without  albumin,  the  existence  of  the 
latter  may  have  been  overlooked. 

To  assert  that  well-marked  nephritis  and  cirrhosis 
may  exist  without  the  appearance  of  albumin  in  the 
urine,  is  a  statement  which  might  possibly  be  regarded 
as  a  theoretical  assumption.  Clinical  and  microscopic 
observations  enable  me,  however,  to  demonstrate  un- 
equivocally the  accuracy  of  my  assertion.  The  follow- 
ing case  will  illustrate  this  : 

In  the  loiddle  of  November,  1881,  while  visiting  the  hospital  as  a 

member  of  the  medical  staff,  a  woman,  Mrs.  X ,  about  forty  years 

of  age,  was  admitted.  She  had  for  many  years  been  addicted  to  the 
inordinate  use  of  stimulants — in  fact,  had  been  a  drunkard.  There 
was  found  to  be  great  enlargement  of  the  liver,  and  there  was  phthisis 
pulmonalis.  There  was  considerable  fever,  with  light  delirium.  There 
was  neither  anasarca  nor  oedema,  but  certain  symptoms,  as  headache 
and  a  disposition  to  stupor,  and  a  peculiar  complexion,  made  me  sus- 
pect the  existence  of  chronic  neiohritis.  Examinations  daily  repeated 
showed  albumin  to  be  absent.  The  sj)ecific  gravity  of  the  urine  was 
about  1020 ;  it  was  acid,  and  rather  scanty.  The  microscopic  exami- 
nation showed :  1,  oxalate  of  lime ;  2,  epithelia  from  the  convoluted 
and  straight  tubules  of  the  kidney ;  3,  epithelia  from  the  pelvis  of  the 
kidney;  4,  epithelia  from  the  ureters;  5,  pus.  My  diagnosis  was 
chronic  interstitial  nephritis  with  cirrhosis. 

December  7th  the  patient  died.  The  autopsy  showed  the  condition 
of  the  lungs  and  liver  as  stated. 

Kidneys  :  size  normal ;  capsule  adherent ;  surface  smooth,  with  nu- 
merous small  retractions  indicating  cin-hosis.  I  have  made  numerous 
sections  of  this  kidney  for  microscopic  examination,  and  studied  them 
carefully.  The  microscojoe  shows  the  interstitial  nejDhritis  to  be  well 
marked,  and  that  the  cirrhosis  was  considerable,  though  not  great. 
The  drawing  (Fig.  5)  showing  the  action  of  chloride  of  gold  on  the 
epithelia  of  the  inflamed  kidney  was  made  from  this  case. 

I  found  also  in  this  case  that  there  was  some  glome- 


NEPHKITIS   WITHOUT  ALBUMINURIA.  147 

rulo-nepliritis  affecting  a  few  of  tlie  tufts,  and  present- 
ing a  phenomenon  which  I  had  never  before  observed 
nor  seen  described.  The  capsular  investment  was  some- 
what thickened,  and  the  tuft  was  atrophied  to  a  third  of 
its  normal  size  and  pushed  into  a  corner,  as  it  were,  of 
the  capsule  by  an  albuminous  exudation  v^^hich,  so  far 
as  could  be  judged  from  the  section,  seemed  entirely  to 
fill  the  capsule. 

The  next  case,  illustrative  of  the  existence  of  nephritis 
for  a  long  time  unaccompanied  by  albuminuria,  is  as 
follows : 

June  1,  1881,  Mr.  Y ,  aged  sixty-seven,  consulted  me.     He  liad 

lost  in  weigiit  thirty  pounds  within  eighteen  months.  There  was  en- 
largement of  the  spleen  of  a  malignant  character,  the  result  of  pre- 
vious malarial  trouble  ;  amount  of  urine  was  considerably  increased. 
Upon  examining  it,  I  found  piis  coi-puscles  and  epithelia  from  the 
straight  and  convoluted  tubules  of  the  kidney ;  no  albumin.  Micro- 
scopic examinations  were  made  every  two  or  three  weeks,  and  the 
same  elements,  generally  in  small  numbers,  were  found,  together 
with  the  oxalate  of  lime.  In  October  and  November  I  found  all  of 
them  greatly  increased,  and,  in  addition,  a  few  epithelia  from  the 
ui'eters  and  the  superficial,  middle,  and  deeper  layers  of  the  bladder. 
Polyuria  continued.  There  was  no  albumin  at  any  time.  Average 
specific  gravity  1018.  The  patient  was  able  to  attend  to  business, 
which  was  not,  however,  exacting. 

Febiiiary  1,  1882,  the  first  uraemic  symptom  that  had  appeared  man- 
ifested itself  in  the  foi-m  of  violent  itching  over  the  whole  body,  con- 
tinuing uninterruj)tedly  night  and  day  until  relieved  by  an  infusion  of 
conium  leaves,  and  producing  prurigo.  On  Febraary  20th  I  found, 
for  the  fu'st  time,  albumin  in  the  urine,  and  three  days  later  there 
occurred  a  slight  hemon-liage  from  the  kidneys,  forming  coagula 
in  the  lU'ine ;  the  microscope  showed  blood  coii^uscles,  pus,  ej)ithe- 
lia  from  the  straight  and  convoluted  tubules,  and  numerous  epithe- 
lia from  the  pelvis  of  the  kidney.  From  this  time  to  date,  June  1st, 
there  have  been  six  hemorrhages,  the  average  intervals  between  them 
being  about  a  week.  None  occiirred  after  June  1st.  The  blood  was 
so  abimdant  as  sometimes  to  produce  small  coagula  in  the  bladder, 
making  the  passage  of  urine  per  urethram  very  difficult. 


148  bright' S   DISEASE. 

Each  analysis  of  tlie  urine  has  sho'mi  the  existence  of  pyelitis,  and 
that  the  blood  came  principally  from  the  pelvis.  Indeed,  nephritis 
affecting  the  tnbe  system  seldom  produces  hemorrhage. 

An  examination  of  the  urine  made  May  1st  shows  the  following  :  l. 
Urine  albuminous ;  2,  crystals  of  oxalate  of  lime ;  3,  red  blood  cor- 
puscles, very  numerous ;  4,  pus  corpuscles,  numerous ;  5,  epithelia 
from  the  middle  and  upper  layers  of  the  bladder,  scanty  ;  6,  epithelia 
from  the  pelvis  of  the  kidney,  very  numerous  ;  7,  epithelia  from  the 
convoluted  tubules  of  the  kidney,  numerous ;  8,  one  hyaline  cast 
found ;  9,  a  few  shreds  of  connective  tissue.  Some  of  the  kidney 
epithelia  contain  a  few  small  fat  granules. 

Diagnosis. — Chronic  catarrhal  (interstitial)  nephritis,  with  intense 
pyelitis,  with  slight  ulceration,  and  slight  cystitis.  Frequent  exami- 
nations gave  the  same  results,  though  the  blood  corpuscles  and  pelvic 
epithelia  greatly  diminished  in  number. 

The  relevance  of  this  case  to  the  subject  of  my  paper 
may  be  thus  stated :  For  a  period  of  nine  months  the 
existence  of  interstitial  nephritis  was  shown  by  the 
microscope,  but  not  until  the  expiration  of  this  time 
were  symptoms  that  might  be  attributed  to  uraemia 
present,  nor  was  albumin  found,  and  its  discovery  was 
soon  followed  by  pyelitis  with  hemorrhage.  The  indi- 
cations of  nephritis  have  now  (June  1,  1882)  for  the  last 
six  weeks  been  apparent  by  ordinary  tests.  I  believe 
the  spleen,  which  is  greatly  enlarged  and  has  undergone 
sarcomatous  degeneration,  must  exert  an  influence  in 
obstructing  the  renal  circulation,  and  may  be  in  this 
case  an  important  factor  in  producing  the  nephritic 
disease.  Disregarding  the  etiology  of  the  nephritis  in 
this  case,  the  fact  remains  that  for  a  long  time  before 
the  appearance  of  albumin  the  proofs  of  the  existence  of 
chronic  catarrhal  nephritis  were  clear. 

Another  case  to  which  I  will  refer  is  that  of  a  lady,  fifty-nine  years 
of  age.  She  has  suffered  for  several  years  from  chronic  muscular 
rheumatism  of  a  severe  character,  with  gouty  tendencies.  On  exam- 
ining the  urine,  in  November,  1881,  I  foimd  jjus  corpuscles,  epithelia 
from  the  convoluted  tubules,  and  hyaline  casts.     Together  with  these 


NEPIIKITIS    WITHOUT   ALBUMIN UKIA.  140 

there  were  crystals  of  oxalate  of  lime  and  uric  acid.  On  examining 
the  lieai-t  I  found  some  hypertroj^hy,  witli  defective  valrular  action, 
the  patient  suffering  frequently  from  palpitation  of  tlie  heart  and 
dyspncea.  There  was  no  trace  of  albumin.  The  general  health  was 
good.  Repeated  examinations  of  the  lu'ine,  made  between  November, 
1881,  and  June,  1882,  showed  the  same  results.  Casts  were  invariably 
present.     (See  also  Appendix  C.) 

Now,  there  is  no  doubt  that  the  case  of  this  lady  is 
one  of  mild  chronic  catarrhal  nephritis,  as  yet  not  ex- 
tensive enough  to  interfere  with  the  renal  functions  or 
to  produce  albuminous  urine.  It  is  one  of  a  numerous 
class  of  cases  of  nephritis  which  may  exist  in  persons  of 
good  constitutions  without  assuming  such  proportions 
as  to  produce  noticeable  symptoms,  or  seeming  to  de- 
teriorate the  health,  and  without  being  accompanied  by 
the  presence  of  albumin.  It  is  this  class  of  cases,  how- 
ever, which  frequently  is  accompanied  by  atheroma  of 
the  arteries,  leading  to  apoplexy,  without  the  ultimate 
cause  of  death  ever  having  been  suspected. 

Albuminuria  cannot  of  itself  he  regarded  as  signif- 
cant  of  nephritis.  Its  persistent  recurrence,  unaccom- 
panied by  au}^  other  known  pathological  condition 
capable  of  producing  it,  is  strong  evidence  in  favor  of 
the  existence  of  the  disease  ;  but  that  is  all,  as  many 
conditions  are  accompanied  by  it,  among  others  those 
which  produce  a  limited  arterial  blood-supply  to  the 
glomerulus,  or  diminish  arterial  pressure.  I  do  not 
allude  to  the  numerous  well-known  causes  of  albumi- 
nuria besides  nephritis,  such  as  are  enumerated  in  Chap- 
ter YIII.,  but  to  those  cases  where  the  coexistence  of  ap- 
parently ursemic  symptoms — as  headache,  nausea,  heart 
troubles,  and  debility — seems  to  indicate  the  existence 
of  nephritis. 

That  the  existence  of  nephritis  in  its  earliest  develop- 
ment— before  the  functions  of  the  kidney  are  markedly 
impaired  and  the  albumin  is  dissevered  from  the  blood 


150  bright' S   DISEASE. 

and  lost  to  the  system,  and  the  nitrogenous  elements 
are  but  scantily  excreted  ;  before  the  thin,  structureless 
membrane  and  delicate  connective  tissue  are  thickened 
into  a  destroying  woof,  and  the  epithelia  swollen  and 
destroyed  ;  before  the  kidney  has  become  contracted 
or  enlarged — is  of  interest  and  importance,  is  evident 
enough.  Not  that  even  then  a  cure  is  always  facile  or 
possible,  but  it  is  during  the  existence  of  this  fleeting 
opportunity  only,  6  raxv<i  Kaipo^,  that  the  course  of  the 
small  stream  which  may  afterward  become  an  invincible 
torrent  can,  if  ever,  be  controlled. 

Upon  the  curability  of  catarrhal  nephritis  I  will  not 
now  touch,  but  will  advert  to  the  means  of  its  recogni- 
tion without  reference  to  the  presence  or  absence  of  al- 
bumin. 

The  convoluted,  irregular,  and  ascending  tubules  are 
lined  by  a  single  layer  of  epithelium,  generally  called 
cuboid  ;  the  descending  branch  of  Henle's  loop,  by  flat 
epithelia ;  and  the  collecting  tubules,  by  columnar  epi- 
thelia. There  is  in  all  these  tubules  but  one  layer,  and, 
when  an  individual  epithelium  dies  as  the  result  of  in- 
flammation, it  is  never  reproduced. 

The  epithelia  of  the  tubuli  contorti  of  the  loop  system, 
magnified  600  diameters,  are  irregularly  angular,  round 
when  swollen,  with  one,  and  rarely  two  nuclei,  and 
magnified  1,000  or  1,200  diameters,  distinctly  showing  a 
reticulum.  Under  this  high  power  the  nucleus,  nucleo- 
lus, nucleolinus,  and  granules  are  distinctly  seen,  form- 
ing the  points  of  intersection  in  the  reticulum.  In  in- 
flammatory conditions  pus  corpuscles  are  formed  in  the 
junctional  points  of  the  reticulum,  which,  having  been 
emptied  from  the  interior  of  the  epithelia,  leave  vacu- 
oles, the  epithelium  often  desquamating.  The  columnar 
epithelium  appears,  when  magnified  500  diameters,  as  an 
elongated  body  having  a  similar 'structure,  but  without 
the  rod-like  formation.     The  pelvic  epithelia  are  gener- 


EPITIIELIA   IN  THE   DIAGNOSIS   OF   NEPHRITIS.        151 

ally  caudate,  but  sometimes  cuboid  or  polyhedral.  In 
interstitial,  as  well  as  in  croupous  nephritis,  the  kidney 
epithelia  are  always  found,  except  when  they  may  be, 
which  rarely  happens,  absent  for  a  short  period.  In  the 
case  of  a  patient  who  recently  died  from  chronic  inter- 
stitial nephritis,  and  who  suffered  from  nearly  all  known 
'ursemic  symptoms,  two  or  three  examinations,  made 
from  four  to  six  weeks  before  his  death,  showed  the 
presence  of  neither  pus  nor  blood  corpuscles,  epithelia 
nor  albumin,  though  this  last  had  nearly  always  been 
found  before.  This,  however,  is,  in  my  experience,  an 
unique  case.  The  autopsy  showed  atrophy,  and  a  high 
degree  of  cirrhosis. 

But  may  epithelia  from  the  kidney  be  found  in  the 
urine  without  the  existence  of  nephritis?  They  m^y 
not. 

1.  There  is  in  the  tubuli  uriniferi  but  one  layer  of 
epithelia. 

2.  Their  presence  never  occurs  without  the  simulta- 
neous presence  of  pus  corpuscles  in  the  urine. 

3.  In  interstitial  and  in  parenchymatous  nephritis, 
epithelia  may  always  be  found. 

4.  Nephritis  never  exists  without  pus  corpuscles  in 
the  urine,  and  blood  corpuscles  can  usually  be  found. 

If  we  discover  in  the  urine  pus  and  kidney  epithelia, 
we  may  conclude  that  there  is  renal  inflammation.  Just 
as  with  pus  and  epithelia  from  the  superficial,  middle, 
and  deep  layers  of  the  bladder  we  should  conclude  that 
cystitis  existed,  or,  with  blood,  pus,  and  epithelia  from 
the  cervix  uteri,  that  there  was  inflammation  of  the 
cervix  uteri. 

ITot  only  from  the  concurrent  existence  of  pus  and 
kidney  epithelia  can  we  diagnosticate  the  existence  of 
nephritis,  but  the  epithelia  will  show  what  region  of  the 
kidney  is  affected,  as  the  pyramidal  substance,  the  pel- 
vis, or  the  cortex. 


152  bright' S   DISEASE. 

Together  with  epithelia  and  pus  corpuscles  and  blood 
will  frequently  be  found  a  few  hyaline  casts.  In  mild 
cases  of  catarrhal  nephritis  this  is  the  only  variety  of 
cast  found,  and,  indeed,  in  severe  and  advanced  cases,  it 
is  very  rare  that  any  other  kind  of  cast  occurs. 

The  importance  of  the  presence  or  absence  in  urine  of 
the  epithelia  of  the  kidney  as  a  means  of  recognition  is 
also  shown  in  the  same  paper,  as  follows  : 

In  diagnosticating  the  epithelia  of  the  kidney,  espe- 
cially those  of  the  convoluted  tubules,  there  is  most  like- 
lihood of  confounding  them  with  epithelia  from  the  pros- 
tate or  from  the  ureters,  and  with  mucous  and  swollen 
pus  corpuscles,  all  of  which  they  closely  resemble. 
Sometimes,  though  rarely,  a  diagnosis  is  impossible. 
They  can  be  distinguished  from  pus  corpuscles  only  by 
their  size  ;  the  pus  corpuscle  must  be  taken  as  the 
standard  of  measurement,  the  epithelium  from  the  con- 
voluted tubes  being  about  half  as  large  again  as  the  pus 
corpuscle.  The  pus  corpuscle  must  be  compared  in  the 
same  drojD  of  urine  and  in  the  same  individual.  It  may 
swell  so  as  to  attain  the  dimensions  of  the  kidney  epi- 
thelium, but  may  be  distinguished  in  such  a  case  by  its 
paler  granulations.  The  accompanying  drawings  rep- 
resent the  ordinary  size  and  appearance  of  the  two, 
magnified  600  diameters. 

The  cuboid  epithelia,  after  immersion  in  the  urine, 
usually  lose  the  cuboid  form  they  possess  while  in  the 
tubuli  uriniferi,  and  become  round  and  swollen. 

I  do  not  in  this  article  refer  to  the  diagnosis  of 
croupous  or  parenchymatous  nephritis,  as  albumin 
may  be  said  in  this  form  of  nephritis  always  to  be 
present. 

There  are,  of  course,  more  details  in  the  diagnosis  of 
nephritis  than  I  can  give  here,  as  I  do  not  pretend  in 
this  paper  to  present  more  than  the  outlines.  The  prac- 
titioner must  familiarize  himself  with  the  appearances 


EPITIIELIA   IN   THE  DIAGNOSIS   OP   NEPHRITIS. 


153 


of  the  epithelia  of  the   entire  genito-urinaiy  tract  of 
each  sex. 

While  it  is  manifest  that  it  is  important  to  be  able  to 
recognize  interstitial  nephritis,  even  in  the  mildest  form, 
I  think  it  should  be  understood  that  the  kidneys  are 
sometimes  so  slightly  affected  by  this  disease  that  its 
discovery  need  not  create  consternation,  nor,  perhaps, 
any  fear  in  the  mind  of  the  patient  or  physician.    Where 


A 


-'A 


B 


^^  Si    g 


I 


c 


D 


Fig.  23. — A,  pus  corpuscles  ;  A,  do.  greatly  swollen  ;  B,  epithelia  from  convoluted  tubules; 
A,  do.  greatly  swollen  ;  C,  epithelia  from  straight  tubules  ;  D,  epithelia  from  pelvis  of  kidney. 


but  a  limited  portion  of  the  kidney  is  affected,  and  in 
but  a  mild  degree,  the  renal  functions  may  continue  to 
be  perfectly  performed,  and  the  general  health  remain 
undisturbed.  I  am  convinced  that,  when  unaccom- 
panied by  the  presence  of  albumin,  many  snch  cases 
exist  without  the  development  of  severe  nephritis,  and 
seemingly  without  deterioration  of  the  health.  Some 
nephritis  probably  exists  in  all  cases  of  tuberculosis ; 
this  fact  is  demonstrated  by  nearly  all  autopsies   of 


154  beight's  disease. 

tubercular  subjects.  Organic  disease  of  the  liver  or 
spleen,  cancerous  affections,  and  high  inflammatory 
conditions  are  often  accompanied  by  it,  without  albu- 
min. At  the  same  time  the  existence  of  nephritis,  even 
in  a  mild  degree  and  without  albumin,  should  lead  to 
the  utmost  vigilance  and  a  careful  observance  of  all 
the  laws  of  hygiene,  and,  if  necessary,  to  remedial 
measures. 

Finally,  the  diagnosis  of  nephritic  disorders  can  be 
neither  satisfactory  nor  possible  unless  the  microscope 
be  employed  as  a  principal  instrument  in  diagnosis. 


CHAPTER  XX. 

CHKONIC  INTERSTITIAL  'NEFKniTIS.— {Continued-). 

Duration. 

This  form  of  nephritis  is,  indeed,  essentially  clironic. 
It  is  sometimes  difficult  to  date  its  origin,  but  so  well  is 
the  nutrition  of  the  system  often  supported,  and  so  well 
does  the  increased  action  of  the  heart  compensate  for 
the  wasted  or  useless  portions  of  the  kidney,  that  sub- 
jects have  been  known  to  live  and  enjoy  a  fair  amount 
of  health  for  many  years — even  twenty.  So  a  recogni- 
tion of  this  form  of  nephritis  may  enable  us,  if  we  can- 
not promise  a  cure,  sometimes  to  hold  out  a  prospect  of 
a  considerable  period  of  life. 

Prognosis. 

Leaving  aside  the  renal  changes,  our  prognosis,  ex- 
cept in  desperate  conditions,  must  be  guided  somewhat 
by  the  constitution  of  the  patient  and  its  freedom  from 
cachexia,  the  position  of  the  patient  as  regards  ability 
to  resort  to  a  suitable  climate,  freedom  from  mental 
and  physical  work,  etc.  Generally,  however,  the  propo- 
sition may  be  stated  that  this  is  more  unfavorable  as 
regards  complete  recovery  than  any  other  form  of  ne- 
phritis. 

When  the  new  formation  and  interstitial  growth  have 
with  the  inflammatory  corpuscles  and  liquid  plasma 
developed  a  f  ally  organized  tissue,  be  permeated  with 


156  beight's  disease. 

new  blood-vessels  ;  wliej  tlie  tubules  and  corpora  Malpi- 
gliiana  are  practically  destroyed,  it  would  be  irrational 
to  suppose  that  the  normal  structure  of  the  kidney 
could  be  restored. 

Still,  there  are  bright  sides  to  this  disease.  Some- 
times a  limited  portion  only — small,  indeed, — of  each 
kidney  will  be  affected,  enough  healthy  kidney  being 
left,  with  the  increased  energy  of  the  heart,  fully  to  per- 
form the  depurative  functions  of  this  gland. 

Again,  there  is  sometimes  a  period,  when  there  is 
simpl}^  serous  effusion  into  the  connective  tissue,  and 
the  alterations  of  the  epithelia  consist  only  in  cloudy 
swelling,  jjerhaps  even  after  the  infiltration  into  the 
connective  tissue  has  become  inflammatory,  and  a  por- 
tion of  the  epithelium  have  desquamated,  that  an  en- 
tirely normal  state  in  the  first  of  the  above  conditions, 
and  a  practically  healthy  state  in  the  second,  may  be 
brought  about. 

I  have  no  doubt  that  many  cases,  as  I  shall  show  in 
the  part  devoted  to  treatment,  recognized  at  an  early 
period,  may  be  cured. 

At  all  events,  by  recognizing  the  importance  of  pre- 
serving the  strength  of  the  heart's  action,  and  by 
proper  treatment,  much  may  be  done  in  many  cases 
toward  prolonging  life  and  making  it  tolerable. 

The  symptoms  indicating  an  unfavorable  termination 
are  :  scanty  urine,  weakness  of  the  heart's  action,  much 
oedema,  albuminous  retinitis,  intense,  constant  head- 
ache, urinous  odor  of  the  skin,  and  prurigo,  coma,  or 
excessive  lethargy. 

Pathological. 

Macroscopic. 

The  kidney  affected  by  this  form  of  disease  has  upon 
its  surface  when  the  capsule,  which  is  thickened  and 


INTEKSTITIAL   NEPHRITIS — PATHOLOGY.  157 

firmly  adherent  to  tlie  adjacent  parts,  is  removed,  small 
projections,  called  granulations,  which  are  about  the 
size  of  millet  seeds.  Cysts  are  frequently  met  with  on 
the  surface,  varying  in  size,  some  of  them  no  larger 
than  the  solid  granules.  These  granulations  must  not 
be  confounded  with  the  white  specks  or  smooth,  whitish- 
yellow  spots  which  are  found  in  croupous  nephritis.  The 
size  of  the  kidney  is  materially  affected,  being  greatly 
diminished,  sometimes  so  much  so  as  to  be  no  larger 
than  a  horse-chestnut.  The  advanced  cirrhotic  kidney 
is  seldom  more  than  half  the  natural  size.  The  disease 
affects  both  kidneys,  and  usually  in  an  equal  degree, 
though  not  invariably  ;  as  in  some  cases  a  portion  of 
one  kidney  may  be  more  affected  than  the  rest  of  it. 
Sometimes,  too,  one  kidney  seems  to  have  been  affected 
by  the  disease  more  rapidly  than  the  other,  causing  an 
inequality  of  size.  The  symmetry  of  the  organ  is  more 
or  less  affected,  in  consequence  of  the  shrinking  of  the 
connective  tissue  taking  place  unevenly.  In  mild  cases 
slight  retractions  are  found,  resembling  indentations 
made  by  a  moderately  dull  instrument.  The  surface  is 
sometimes  smooth  ;  the  color  being  usually  reddish- 
brown,  though  sometimes  it  is  pale  and  almost  white, 
according  to  the  amount  of  blood  contained  in  different 
cases.  All  parts  of  the  kidney  show  to  the  naked  eye 
gray,  radiating  stride,  which  under  the  microscope  are 
found  to  be  newly  formed  connective  tissue  ;  and  it  is 
the  retraction  of  this  that  causes  the  retractions  on  the 
surface. 

When  the  kidney  is  contracted,  the  great  loss  of  di- 
ameter is  usually  in  the  cortical  portion,  though  the 
P3a"amidal  will  sometimes  be  wasted  in  an  equal  degree. 
When  interstitial  nephritis  lasts  considerable  time  it  in- 
variably leads  to  cirrhosis. 

In  certain  cases,  in  the  commencing-  stage  of  this 
disease,  the  kidney  will  be  found  to  be  of  normal  size. 


158  beigiit's  disease. 

or  slightly  enlarged,  and  the  capsule  but  slightly  ad- 
herent, and  in  others  considerably  hypertrophied,  being 
analogous  in  this  respect  to  cirrhosis  of  the  liver. 

Microscopic. 

It  is  in  the  connective  tissue  that  we  should  naturally 
expect  to  find  the  greatest  changes.  We  find,  there- 
fore, especially  in  the  labyrinth,  an  increased  growth 
of  fibroid  tissue,  interspersed  with  medullary  corpus- 
cles, becoming  in  time  permeated  with  blood-vessels. 
This  interstitial  proliferation  always  exists  in  this  form 
of  nephritis. 

The  fibrous  growth  occurs  around  the  blood-vessels 
and  the  corpora  Malpighiana^  especially  about  the 
capsule,  which  is  itself  thickened  and  adherent.  The 
new  growth  extends  inward  from  the  cortical  layer, 
imbedding  the  Malpighian  tufts  and  tubules  ;  extend- 
ing'farther  inward  it  becomes  more  diffused,  spreading 
between  and  compressing  the  coRvoluted  and  collecting 
tubules.  This  growth  of  fibrous  tissue  cannot  occur 
without  involving  other  important  anatomical  changes 
in  all  the  parts  encompassed  by  it.  The  convoluted 
tubules  become  contracted,  and  many  of  them  reduced 
to  mere  threads,  through  which  no  passage  remains ; 
some  normal  tubules  are  found  in  the  new  formation, 
having  healthy  epithelia  and  healthy  Malpighian  bodies 
attached  to  them.  The  tubules  are  not  uniformly 
affected,  as  it  is  the  character  of  the  disease  that  the 
increase  of  fibrous  tissue  does  not  take  place  uniformly, 
but  at  points  a  little  removed  from  each  other. 

As  regards  the  changes  in  the  blood-vessels,  according 
to  Greene  : ' 

"The  first  thing  noticed  is  that  the  lining  endothelia 

^  Heitzmann's  Morphology,  p.  770. 


INTERSTITIAL   NEPHRITIS — PATHOLOGY. 


159 


of  the  artery  are  enlarged  and  coarsely  granular,  and 
that  a  proliferation  of  inflammatory  corpuscles  takes 
place,  encroaching  upon  the  caliber,  rendering  it  irreg- 


FiG.  24. — Cirrhosis  of  the  Kidney.  High  Degree. — A,  striated  and  hypertrophied  con- 
nective tissue  ;  B,  tuft  striated  and  surrounded  by  C,  connective  tissue ;  D,  transverse  sec- 
tion of  small  tubule  converted  into  connective  tissue  ;  E,  convoluted  tubule,  partially  obliter- 
ated, with  endothelia ;  F,  empty  convoluted  tubule,  cross  section ;  G,  small  tubule,  its 
epithelia  in  process  of  conversion  into  connective  tissue ;  H,  cross-section  of  tubule  with 
epithelia  nearly  normal  ;  I,  tubules  containing  endothelia  and  partially  disintegrated  epi- 
thelia ;  J,  tuft  compressed  aud  shrunken,  the  capsule  being  fiUed  up  by  the  albuminous  fluid, 
K ;  L,  thickened  capsule  ;  M,  cross-section  partially  empty  tubule  with  wasted  epithelia.  (Mag- 
nified 500  diameters.) 

ular,  as  if  compressed.  Often,  however,  the  narrowed 
lumen  contains  a  finely  granular  or  homogeneous  mass, 
probably  plasma  of  the  blood.  The  spindles  of  the 
smooth  muscle-fibres  of  the  middle  coat  are  transformed 


160  beight's  disease. 

into  inflammatoiy  corpuscles.  These  bodies,  at  first, 
are  not  numerous,  but  in  more  advanced  stages  appear 
to  compose  the  entire  tissue,  which  still  preserves  a 
resemblance  to  the  original  smooth  muscle-structure. 
These  characteristics  are  particularly  well  marked  in 
transverse  sections,  where  a  decided  increase  in  the  cir- 
cumference of  the  vessel  is  also  noticed.  Similar 
changes  take  place  in  the  external  coat,  till  finally  the 
entire  arterial  wall  is  converted  into  a  solid  connective- 
tissue  cord,  which  may,  in  places,  still  show  faint  traces 
of  the  former  caliber." 

The  changes  in  the  tufts  are  various ;  the  capsules 
are  distended  and  covered  with  inflammatory  nuclei, 
originating  from  the  covering  epithelia  and  from  the 
endothelia  of  the  capillaries,  which  latter  become  thick- 
ened and  like  a  solid  cord.  These  break  down  into  in- 
flammatory corpuscles,  and  the  capsule  seems  covered 
by  them.  The  capsule  is  greatly  thickened.  Finally, 
the  medullary  corpuscles  become  converted  into  con- 
nective tissue,  containing  but  very  few  inflammatory 
corpuscles. 

In  some  cases  of  cirrhosis  the  tuft  will  be  found  en- 
larged, and  filled  with  albuminous  exudate  and  covered 
with  inflammatory  corpuscles  ;  in  other  cases  it  is 
greatly  swollen  ;  the  thickened  tuft  is  often  found  to 
be  affected  by  waxy  degeneration. 

Chaistges  in  the  Tubules. 

The  first  phenomena  observable  in  acute  interstitial 
nephritis  in  the  tubules  must  necessarily  be  cloudy 
swelling,  or  an  increased  bulkiness  of  the  reticular 
structure  of  the  epithelium.  This  occurs  to  a  greater  or 
less  degree  in  the  very  first  stage  of  oedema  of  the  con- 
nective tissue ;  if  this  last  do  not  subside,  we  have  a 
series  of  changes  similar  to  that  which  occurs  in  chronic 


INTEKSTITIAL   NEPHRITIS — CHANCtES   IN   TUBULES.      161 

croupous  nepliritis,  namely,  desquamation  of  tlie  epi- 
tlielia  ;  formation  from  the  points  of  junction  in  the 
reticulum,  of  inliammatory  corpuscles  which  become  de- 
veloped into  pus  corpuscles  ;  disintegration  of  the  epi- 
thelia,  or  breaking  down  into  finely  granular  matter, 
and  replacement  of  the  perished  epithelia  by  endothelia. 
The  rod-like  structure,  thickened  by  the  inflammatory 
process,  I  have  repeatedly  found  in  convoluted  and 
straight  tubules.  The  conversion  of  the  epithelia  into 
exudate,  forming  casts,  is  not  common,  but  does  never- 
theless occur,  though  in  a  limited  way ;  and  the  casts 
formed,  I  believe,  are  invariably  hyaline.  The  basement 
membrane  becomes  infiltrated  and  has  a  glassy  look, 
and  the  connective  tissue  is  noticeably  increased.  The 
various  gradations  from  fine  filtrations  to  coarse  striae 
may  be  easily  traced. 

In  many  of  the  epithelia  the  nucleus  or  nucleolus 
will  be  found  changed  into  shining  lumps  of  living 
matter  ;  these  are  separated  by  narrow  rims  of  cement- 
substance,  but  are  united  by  fine  threads.  Many 
tubules  will  be  found  covered  by  these  shining  lumps, 
which  are  stained  red  by  carmine.  In  many  of  the 
tubules,  when  the  nephritis  produces  cirrhosis,  the  epi- 
thelia become  converted  into  connective  tissue,  in  which 
case  the  basement  membrane  is  obliterated.  (Fig.  24,  D 
and  Gf.) 

This  is  what  occurs  to  those  of  the  infiamed  epithe- 
lia which  are  not  destroyed,  degenerated,  or  disinte- 
grated, and  it  is  in  this  manner  that  the  growth  of 
connective  tissue  takes  place  in  cirrhosis. 

A  similar  process  invades  the  interstitial  tissue.  It  is 
filled  with  medullary  or  inflammatory  corpuscles ;  as 
suppuration  of  this  tissue  does  not  occur  in  interstitial 
nephritis,  the  medullary  corpuscles  form  connective  tis- 
sue instead  of  going  on  to  the  development  of  pus  cor- 
puscles. Cirrhosis  always  arises  from  non-  siippuratwe 
11 


162  bright' S   DISEASE. 

nephritis.  Endotlielia  are  usually  formed  after  the  de- 
struction of  the  epithelia,  when  the  tubule  is  not  wholly 
or  partially  obliterated. 

The  epithelia  often  becomes  the  seat  of  waxy  and 
fatty  degeneration,  though  less  frequently  than  in 
croupous  nephritis. 


PART  II.-TREATMENT. 


CHAPTER  XXL 

THE  TREATMENT  OF  ACUTE  NEPHRITIS. 

In  acute  nex^liritis  more  rapid  relief  will  be  effected  if 
the  recumbent  position  be  maintained.  The  efficacy  of 
rest  in  diminishing  the  exudation  of  albumin  has  often 
been  demonstrated.  Bartels  (in  "Ziemssen")  gives  an 
account  of  a  case  of  chronic  interstitial  nephritis  in  a 
young  man,  in  which  the  occurrence  of  albumin  in  the 
urine  could  always  be  prevented  by  keeping  the  patient 
in  bed,  the  albumin  invariably  returning  when  the  pa- 
tient sat  up.  There  is  no  reason  why,  even  in  compara- 
tively mild  cases  of  acute  nephritis,  the  same  injurious 
effects  should  not  be  produced  upon  the  acutely  in- 
flamed kidney  by  movement,  as  is  produced  in  pneu- 
monia, hepatitis,  etc.  Rest  in  acute  nephritis  is  of  the 
greatest  importance.  I  have  met  with  a  number  of 
cases  in  the  convalescent  stage  in  which  the  albumin 
had  nearly  disappeared,  but  would  be  temporarily 
brought  back  by  sitting  up  or  by  moderate  exercise 
in  the  room.  Whatever  increases  the  activity  of  the 
heart's  action  must  affect  the  activity  of  the  renal  cir- 
culation, bringing  about  albuminous  exudation,  perhaps 
in  the  manner  described  in  Chapter  YIII.  From  the 
facts  there  given,  the  effects,  even  in  health,  of  great 
exertion  upon  albuminous  exudation  are  apparent.  The 
patient,  until  safety  is  assured^  should  be  kept  in  bed. 


164  bright' S   DISEASE. 

Dietetic  Measuees. 

Highly  nitrogenized  food  sliould  be  avoided,  such,  for 
instance,  as  tends  to  excessive  formation  of  nric  acid. 
At  the  same  time  due  regard  must  be  had  to  support- 
ing the  patient's  strength.  Liglit  animal  broths  can 
generally  be  given,  while  oysters  and  milk  may  be  par- 
taken of  freely.  Sometimes  fowl  or  game  may  be  given, 
and  fish  may  be  freely  eaten.  Light  acid  wines  should 
ordinarily  not  be  objectionable.  Fruits,  vegetables,  and 
cereals  are  suitable. 

Remedial  Measuees. 

Diaphoresis  is  invaluable  and  almost  indispensable  ; 
nitrogenized  elements  which  should  escape  by  the  skin 
and  are  retained  in  the  system,  forming  toxic  elements, 
are  liberated,  the  work  of  secretion  is  thereby  removed 
somewhat  from  the  overburdened  secreting  and  separat- 
ing apparatus,  and  in  addition  the  venous  and  arterial 
pressure  and  plethora  of  the  renal  vessels  are  lessened 
by  cutaneous  hypergemia,  the  blood  circulates  in  the 
kidneys  with  less  difficulty,  and  consequently  the  sep- 
arating or  formative  capacity  of  the  epithelia  is  in- 
creased. Not  only  is  the  amount  of  albumin  dimin- 
ished, but  the  quantity  of  urine  is  increased.  Diaphor- 
esis, brought  about  as  I  shall  describe,  in  many  in- 
stances is  followed  by  a  favorable  change  with  almost 
magical  rapidity,  the  urine  becoming  for  the  time  al- 
most natural.  I  usually  resort  to  the  hot-air  bath,  and 
by  means  of  it  the  skin  can  be  made  to  excrete  an  enor- 
mous quantity  of  fluid.  In  addition  to  the  excellent 
effect  upon  the  kidney,  oedema  and  dropsical  effusions 
are  very  much  diminished  by  its  use.  The  simplest  and 
most  easily  obtained  hot-air  bath,  and  the  one  I  usually 
employ,  is  Ronchetti'  s  ;  it  is  generally  kept  by  instru- 


TREATMENT   OF   ACUTE   NEPHRITIS.  165 

ment  dealers.  It  is  simple  in  its  construction,  consist- 
ing of  a  tin  box  15|-  inches  in  length  and  6^  inches  in 
height  and  width.  Through  the  centre  runs,  longitu- 
dinally, a  pipe,  projecting  at  each  end,  one  end,  the 
larger,  being  bent  downward  at  a  right  angle  ;  at  the 
opening  of  this  end  is  j)laced  a  spirit  lamp  with  a  large 
wick.  I  have  found  the  thermometer  to  show  under 
the  bedclothes  a  temperature  of  160°  F.  The  bedclothes 
should  be  raised  up  so  as  not  to  come  in  contact  with 
the  box.  The  sweating  process  is  induced  in  a  very 
thorough  manner,  usually  in  twenty  minutes.  In  some 
cases  the  skin  is  so  dry  and  unperspirable  that  upon  the 
first  attempt  perspiration  is  induced  very  slowly  and 
imperfectly  ;  after  one  or  two  trials,  however,  the  skin 
readily  responds  and  profuse  sweating  ensues. 

The  sweating  process  completed,  I  direct  affusion  with, 
moderately  cold  water,  followed  by  rubbing  with  equal 
parts  of  alcohol  and  water.  The  patient  is  then 
wrapped  in  hot  woollen  blankets.  By  the  use  of  cold 
water,  alcohol,  and  thorough  rubbing,  the  activity  of 
the  cutaneous  circulation  is  restored  and  the  sensitive- 
ness of  the  skin  diminished  ;  without  this  after-treat- 
ment it  is  left  in  a  weak  and  sensitive  condition,  and 
the  danger  of  taking  cold  incurred.  Whether  or  not 
diaphoresis  be  induced,  great  attention  must  always  be 
paid  to  the  integrity  of  the  functions  of  the  skin.  It  is 
in  derangements  of  this  great  emunctory  that  a  large 
proportion  of  cases  of  nephritis  originate  ;  and  a  restora- 
tion of  its  normal  action  is  indispensable  to  the  relief  of 
the  surcharged  renal  vessels  and  the  embarrassed  renal 
circulation.  The  hot-air  bath  should  be  employed 
daily,  or  on  alternate  days,  until  permanent  relief  is 
established,  or  so  long  as  it  seems  to  be  of  use. 

Dr.    G.   Johnson'  recommends    "a  wet  sheet    and 

1  Briglit's  Disease,  American  ed.,  p.  134. 


166  bright' S   DISEASE. 

blanket-bath.  A  sheet  is  wrung  out  of  warm  water,  and 
the  patient,  either  naked  or  covered  only  by  his  shirt,  is 
enveloped  in  the  wet  sheet  up  to  the  neck.  Then  three 
or  four  dry  blankets  are  closely  folded  over  the  wet 
sheet.  He  may  remain  thus  packed  from  two  to  four 
or  six  hours,  or  even  longer.  If  the  packing  be  long 
continued  the  sheet  has  to  be  rewetted  as  soon  as  it  be- 
comes dry.  The  evaporation  and  consequent  drying  of 
the  sheet  will  be  slow  in  proportion  to  the  closeness  of 
the  blanket  packing.  If  the  outer  blanket  be  covered 
by  a  mackintosh  cloth  the  sheet  remains  wet  for  a  much 
longer  time  than  when  no  waterproof  covering  is  used  ; 
but  patients  often  complain  of  a  feeling  of  oppression 
when  surrounded  by  the  impervious  mackintosh.  The 
advantage  of  the  blanket-bath  over  a  warm-water  or  hot- 
air  bath  is  that  it  requires  no  special  apparatus,  that 
the  diaphoretic  action  may  be  more  prolonged,  and  that 
in  most  cases  it  is  more  agreeable  to  the  patient.  The 
hot-air  bath  not  unfrequently  causes  an  unpleasant 
throbbing  in  the  head,  or  a  feeling  of  exhaustion  and 
even  faintness.  When  the  wet  pack  is  removed  the 
patient  should  be  quickly  rubbed  dry  and  enveloped  in 
dry  blankets.  The  diaphoretic  action  of  any  form  of 
warm-water  bath  is  assisted  by  copious  libations  of 
simple  diluent  drink." 

I  have  not  employed  the  above  method,  but  it  pos- 
sesses the  advantage  of  requiring  no  apparatus,  and  of 
being  borne  when,  on  account  of  heart  trouble,  the  hot- 
air  bath  might  not  be. 

A  very  convenient  form  a  vapor  bath  is  that  of  Henry 
Lee,  of  London.  It  consists  essentially  of  a  Davy's 
safety  lamp,  above  which  is  a  small  copper  reservoir, 
of  a  size  to  contain  sufficient  water  to  create  steam 
enough  for  a  vapor  bath.  This  is  placed  under  a  chair 
with  a  cane  bottom,  or  under  sbme  sort  of  an  open  seat, 
and  the  patient  sits  over  it,  being  covered  with  a  large 


TKEATMENT   OF   ACUTE   NEPHEITIS.  167 

blanket  or  rubber  mackintosli  reaching  to  the  floor. 
This  bath  should  also  be  followed  by  cold  water  and 
spirits. 

Jahorandi  and  its  alkaloid  pilocarpine  are  remedies 
from  which,  in  nephritis,  particularly,  if  oedema  or 
dropsy  be  present,  we  should  expect  to  derive  benefit. 
They  are  to  be  thought  of  when  diaphoresis  is  needed  ; 
and  when  they  can  be  taken  without  nausea,  headache, 
or  prostration  resulting,  will  often  prove  useful.  Of  the 
diuretic  effects  attributed  by  some  authors  to  this  rem- 
edy I  have  but  an  indifferent  opinion.  When  the  stom- 
ach will  not  tolerate  it,  it  can  be  given  per  rectum,  or 
the  pilocarpine  can  be  given  hj^podermically  in  doses 
of  4V  ^o  ^Vj  oi"  6^6^  ^6iy  gnardedly  to  an  adult,  ^  of  a 
grain.  Of  the  jaborandi,  the  fluid  extract  is  the  most 
reliable  preparation.  The  average  dose  to  an  adult  is 
30  drops  every  two  hours ;  when  it  acts  at  all  it  produces 
prompt  and  profuse  sweating.  This  remedy  serves  when 
enfeebled  or  oppressed  action  of  the  heart  would  make 
the  hot-air  bath  dangerous.  It  is,  however,  somewhat 
nauseating.  Its  sialagogue  and  diaphoretic  properties 
cannot  always,  however,  be  relied  upon,  as  is  shown  in 
Case  YIIL,  the  case  being  one  of  acute  croupous  ne- 
phritis in  a  child  of  eight  years,  with  complete  suppres- 
sion of  urine  lasting  thirty-four  hours,  in  which  I  ad- 
ministered, in  a  single  day,  without  any  effect,  diapho- 
retic, sialagogue,  or  even  nauseating,  nearly  half  an 
ounce.  Nevertheless,  some  physicians  have  found  it  of 
great  value. 

Dr.  J.  M.  Da  Costa  publishes  in  the  Clinical  Gazette 
an  account  of  what  was  evidently  acute  hemorrhagic 
croupous  nephritis,  which  was  cured  by  jaborandi ;  a 
drachm  of  the  fluid  extract  being  given  three  times  a 
day.  Profuse  sweating  and  diuresis  were  produced. 
Dr.  Chew  {Neio  Orleans  Medical  Journal)  gives  a  case 
of  acute  croupous  nephritis,  occurring  in  a  lad  twenty 


168  bright' S   DISEASE. 

years  of  age,  with  oedema  and  ascites.  Thirty  drops 
fl,  ext.  jaborandi  were  given  every  two  hours,  and  con- 
tinued during  the  day,  for  two  days.  Diaphoresis  was 
immediate  and  profuse ;  at  the  expiration  of  two  days 
the  oedema  had  disappeared,  and  tliere  was  not  a  trace 
of  albumin  in  the  urine.  Dr.  Burke,  of  JSTew  York 
{Medical  Record)^  describes  a  case  of  nephritis  in  a  par- 
turient female,  producing  puerperal  convulsions,  which 
were  controlled  by  the  hypodermic  injection  of  \  grain 
of  pilocarpine.  In  another  case  he  employed  a  rectal 
injection  of  30  drops  fl.  ext.  jaborandi ;  this  was  followed 
by  dangerous  oedema  pulmonum,  which  was  controlled 
with  difficulty.  An  injection  of  pilocarpine,  grain  ^Vj 
though  it  stopped  the  convulsion  and  did  not  occasion 
much  oedema,  did  not  avert  a  fatal  result  from  prostra- 
tion. As  jaborandi  may  produce  profuse  bronchial  se- 
cretion, the  danger  from  this  source  must  not  be  over- 
looked. A  case  of  "albuminuria,"  occurring  in  a  lady 
three  months  advanced  in  pregnancy,  is  reported  as 
having  been  cured  by  Dr.  Langfelt,  of  Rheims.  The 
patient  took  the  drug  continuously  for  sixteen  days. 
The  benefit  seems  to  have  been  derived  from  its  siala- 
gogue  properties. 

DiUEETICS. 

These  are  of  great  value,  and  often,  indeed,  indispen- 
sable. Ordinarily  they  are  of  most  value  when  there  is 
oedema  or  dropsical  effusions,  particularly  of  the  peri- 
cardial sac,  the  lungs,  or  pleural  cavities.  In  many 
cases  of  nephritis  they  are  of  value  in  flushing  the  tu- 
bules with  the  supply  of  water  which  they  require,  if 
only  to  carry  away  excreta  and  urinary  salts.  Their 
use  is  certainly  often  followed  by  increased  specific 
gravity  of  the  urine,  and  an  increased  amount  of  urinary 
salts.     If  the  opinions  of  various  authors  be  correct,  that 


ACUTE   NEPHEITIS — TREATMENT — DIURETICS.        169 

spontaneous  diuresis  often  relieves  renal  congestion  and 
inflammation,  diuresis  artificially  induced  may  also  have 
a  correspondingly  beneficial  effect.  It  is  true  tliat  a  free 
action  of  skin,  bowels,  or  kidneys  is  followed  by  relief 
to  the  renal  derangement.  Certainly,  diuretics  that  can 
aid  in  the  prevention  of  the  formation  of  elements  in 
the  blood  which  produce  ursemic  poisoning,  must  be  of 
value. 

In  the  selection  and  administration  of  diuretics,  the 
following  results  should  be  sought  for  : 

1st.  In  case  of  accumulation  of  fluids  in  cavities  or 
cellular  tissue,  to  diminish  the  effused  fluid  by  an  in- 
creased flow  of  urine. 

2d.  In  case  of  anuria  or  diminished  secretion  of  urine, 
to  increase  the  flow. 

3d.  In  the  latter  case  especially,  to  administer  such 
diuretics  as  will,  if  such  a  thing  be  possible,  increase 
the  formation  in  the  tiibuli  uriniferi  of  urea. 

Diuretics  act  variously ;  some  by  increasing  arterial 
and  venous  tension,  thereby  increasing  the  fulness  and 
pressure  of  the  renal  vessels  and  the  velocity  of  the 
blood-current ;  some  by  endowing  the  left  ventricle  with 
increased  contractile  power,  while  others  (it  is  thought) 
augment  the  diffusibility  and  solubility  of  substances  in 
the  blood  by  furnishing  an  increased  supply  of  oxygen, 
thereby  facilitating  the  conversion  by  the  epithelia  into 
urea,  of  effete  substances  in  the  blood.  According  to 
Beale,'  many  neutral  salts,  as  nitrates,  sulphates,  etc., 
seem  to  increase  the  secretion  of  urine  by  being  attracted 
from  the  blood  in  a  state  of  solution,  in  all  probability 
by  the  renal  epithelia.  Urea  has  a  similar  diuretic  ac- 
tion. Within  certain  limits,  the  greater  the  quantity 
of  these  substances  in  the  blood  the  more  will  be  re- 
moved by  the  epithelia,  supposing  it  to  be  healthy. 

'  Loe.  cit. 


170  beight's  disease. 

Alkalies,  and  especially  the  citrates,  tartrates,  and  ace- 
tates, which  become  converted  into  carbonates  in  the 
system,  increase  not  only  the  quantity  of  water  removed 
from  the  system,  but  also  materially  augment  the  total 
amount  of  solid  matter  removed  from  the  body  in  a 
given  time.  These  salts  increase  the  quantity  of  urea 
and  other  matters  formed.  They  seem  to  favor  the  con- 
version of  the  products  resulting  from  the  disintegration 
of  tissue  into  these  constituents.  The  alkali  perhaps 
facilitates  the  process  of  oxidation  going  on  in  the  urin- 
iferous  tubes.  The  action  of  such  remedies  is  very  de- 
sirable in  a  vast  number  of  cases,  and  even  where  the 
kidneys  are  diseased,  these  salts  act  favorably.  Atro- 
pine (Parkes),  digitalis,  and  colchicum,  like  alkalies, 
increase  the  proportion  of  urinary  solids  ;  the  favorable 
action  of  the  last  two  in  gout  is  probably  to  be  explained 
by  their  influence  in  encouraging  the  formation  of  urin- 
ary constituents. 

Some  diuretics,  as  squills  and  broom  (scoparius),  cause 
an  increased  secretion  of  water,  but  not  directly  that  of 
solid  matter  (Beale).  Cantharides  in  small  doses,  one  or 
two  drops  of  the  tincture  in  an  adult,  is  often  of  great 
use  in  enfeebled  conditions  of  the  renal  circulation. 
Scilla  is  also  an  irritant,  though  in  a  less  degree  than 
cantharides,  and  has  more  of  a  diuretic  action. 

Digitalis,  in  acute  nephritis,  is  one  of  the  most  valu- 
able of  diuretics.  It  is  essentially  a  hydragogue,  but 
an  increased  secretion  of  water  also  favors  the  formation 
of  urea  ;  in  passive  venous  congestion  of  the  renal  capil- 
laries, in  general  venous  congestion  from  defective  action 
of  the  tricuspid  (right  auriculo-ventricular)  valves,  in 
enfeebled  muscular  power  of  the  left  ventricle  and  of 
the  cardiac  plexus,  its  effects  are  often  remarkable  ; 
stimulating  the  vaso-motor  pressure  and  the  muscular 
power  and  circulation  of  the  arterioles,  it  corrects 
enfeebled  and  languid  circulation,  either  venous  or  ar- 


ACUTE   NEPHEITIS — TREATMENT — DIURETICS.        171 

terial,  increases  the  pressure  in  the  vessels  of  the  glom- 
erulus, and  augments  aqueous  secretion.  In  the  condi- 
tions above  described,  and  with  scanty  urine  or  anasarca, 
or  dropsy,  it  is  sometimes  almost  indispensable  ;  it  also 
possesses  the  great  advantage,  in  acute  inflammatory 
conditions,  of  not  being  an  irritant.  The  muriate  of 
iron  with  it  is  often  of  great  use.  An  excellent  diuretic 
mixture  in  cases  where  digitalis  is  indicated  is  the  fol- 
lowing : 

Tinct.  digitalis 1  ss. 

Yini  scillse !  jss. 

Spiritus  setheris  nitrici o  ij- 

A  teaspoonful  every  three  or  four  hours. 

Where  an  alkaline  diuretic  is  likely  to  be  useful 
in  combination  with  digitalis  and  squills,  Trousseau's 
diuretic  wine  would  be  found  an  excellent  formula, 
namely  : 

Junip.  contus <■    3  x. 

Pulv.  digitalis 3  ij. 

Pulv.  scillse. 3  ]". 

Yin.  Xerici Oj. 

Macerate  for  four  days  and  add 

Potas.  acetatis 3  iij. 

Express  and  filter, 

S.  A  tablespoonful  three  times  a  day 
for  an  adult. 

Convallaria  majalis  (Lily  of  the  Yalley)  is  a  remedy 
likely  to  be  of  great  use  in  nephritis  with  insufficient 
power  of  the  left  ventricle  of  the  heart.  The  first 
important  accounts  of  this  plant  were  given  in  this 
country  by  Dr.  Ralph  d'Ary,  of  Romeo,  Mich.,  who 
furnished  in  the  Therapeutic  Gazette  of  October,  1881, 
his  own  experience,  and  also  gave  1;ranslations  of  ar- 


172  bkight's  disease. 

tides  by  eminent  Russian  physicians.  The  next  im- 
portant contributions  relative  thereto  were  given  by  Dr. 
E.  P.  Hurd  in  the  Medical  Record  of  September  9,  1882, 
presenting,  in  addition  to  his  own  valuable  observations, 
the  conclusions  and  experience  of  Prof.  Germain  See,  of 
Paris.  The  results  of  its  use  at  the  Roosevelt  Hospital 
have  been  published  in  the  Medical  Record  (January  27 
and  February  3,  1883).  It  proved  of  great  value  in  a 
number  of  cases  of  chronic  "  Bright's  disease  "  (appar- 
ently chronic  croupous  nephritis)  with  scanty  urine. 
The  heart  was  variously  affected  ;  in  one  instance,  some- 
what hypertrophied  ;  in  another,  ' '  heart  sounds  very 
weak;"  another,  "double  cardiac  impact  and  double 
first  sounds  ;  "  in  a  fourth,  "mitral  systolic  murmur." 

Under  its  use  the  urinary  secretion  was  generally 
greatly  increased,  though  the  amount  of  albumin  was 
not  diminished.  In  a  number  of  cases  of  deficient  cir- 
culation from  organic  cardiac  disease,  most  of  them 
being  accompanied  by  oedema  or  dropsy,  and  diminished 
urine,  digitalis  having  been  previously  employed  in  all 
of  them,  greater  relief  was  derived  from  this  than  from 
any  other  remedy.  In  one  case,  however,  especially  of 
mitral  regurgitation  in  a  woman  fifty  years  of  age,  there 
was  diminution  of  urine,  orthopnoea,  slightly  albumi- 
nous urine;  heart  action  irregular;  impossibility  of 
lying  down,  on  account  of  dyspnoea ;  at  one  time,  Oc- 
tober 27th,  general  anasarca  below  the  waist ;  pulse 
and  breathing  very  bad.  Her  death  had  been  expected 
from  hour  to  hour.  The  tincture  of  digitalis  was  in- 
creased to  th  XX.  q.  4  h.,  and  the  legs  punctured  with 
needles. 

The  urine  was  in  a  few  days  increased  from  20  oz.  or 
less  to  40  or  50  daily  ;  and  such  great  relief  was  brought 
about  that,  on  December  7th,  she  was  ' '  discharged  im- 
proved." 

In  the  early  part* of  the  treatment  of  this  case  at  the 


ACUTE   NEPHRITIS — TREATMENT — CONVALLARIA.      173 

hospital,  convallaria  was  employed,  with  only  tempo- 
rary benefit.  It  relieved,  however,  to  an  equal  extent 
with  digitalis,  a  case  of  aortic  stenosis  in  a  man,  aged 
fifty-two,  with  scanty  and  albuminous  urine,  urgent 
dyspncBa,  hiccoughing,  and  orthopnoea,  digitalis  having 
been  administered  without  benefit. 

Cases  are  reported  in  the  Medical  Record,  February 
3,  1883,  of  relief  having  been  afforded  by  this  plant  in 
extremely  rapid  action  of  the  heart  and  great  irregular- 
ity of  the  heart' s  action ;  and  Hurd  reports  a  case  of 
Corrigan's  disease  benefited  by  it,  in  which  there  was 
hydrothorax,  the  urine  being  increased  from  an  aver- 
age amount  of  8  oz.  to  60  oz.  daily. 

The  same  author  {TTier.  Gazette,  July,  1883)  gives  cases 
of  mitral  insufficiency  with  cardiac  dilatation  and  hyper- 
trophy, general  anasarca  and  ascites,  cured  by  conval- 
laria. Half  a  teaspoonful  of  the  fluid  extract  of  the 
root  was  given  every  four  hours ;  of  general  dropsy  from 
mitral  disease,  marked  amelioration  being  produced  by 
drachm  doses  every  four  hours,  and  of  aortic  insuffi- 
ciency with  hydrothorax  greatly  relieved  by  drachm 
doses  every  four  hours.  Prof.  See  found  that  in  cer- 
tain cases  of  heart  disease  the  urine  was  increased  in 
twenty-four  hours  from  one  to  six  or  seven  pints. 

Prof.  Beverly  Robinson,  in  a  valuable  paper  in  the 
Therapeutic  Gazette,  July  and  August,  1883,  does  not 
find  this  plant  to  be  a  valuable  renal  stimulant,  men- 
tioning a  case  of  asystolie  with  insufficient  excretion  of 
urine  ;  the  heart's  action  was  not  benefited  by  it,  but  it 
produced  abundant  diuresis.  The  functional  sphere  of 
this  remedy  is  by  no  means  yet  definitely  fixed.  It  has 
not  yet  been  shown  that  convallaria  is  in  itself  a  diuretic, 
but  it  seems  to  affect  the  kidneys  mainly  through  its 
influence  upon  the  heart.  I  have  had  the  most  favorable 
experience  with  it  in  croupous  nephritis  with  diminished 
secretion  of  urine,  when  accompanied  by  feeble  action 


174  bright' S   DISEASE. 

of  the  heart,  cardiac  insufficiency,  and  valvular  derange- 
ments. 

According  to  Prof.  See,  it  is  of  value  in  palpita- 
tions, mitral  constrictions,  in  insufficient  compensation 
of  the  right  ventricle  and  left  auricle,  dyspnoea,  mitral 
insufficiency,  dilatation  of  the  left  ventricle,  and  in  cardo- 
pathies  with  dropsy.  It  produces  augmentation  of  the 
energy  of  the  heart,  and  its  diuretic  effects  are  likely  due 
to  this  power.  Its  most  marked  effects  are  considered 
by  some  who  have  used  it  to  be  upon  the  right  heart, 
but  the  cases  in  which  it  was  employed  seem  to  indicate 
an  equal  influence  in  every  direction  of  the  cardiac 
nerves.  It  is  a  remedy  of  which  much  is  to  be  expected 
in  affections  of  the  kidney  connected  with  cardiac  de- 
rangements, but  whose  exact  place  and  applicability 
future  investigations  must  show.  It  is  undoubtedly 
destined  to  supplant  digitalis  to  a  considerable  extent. 

Dr.  Hurd  states  that  the  first  detailed  accounts  of  its 
action  and  efficiency  in  cardiac  diseases  were  published 
by  two  Russian  physicians  in  1880,  although  it  has  been 
used  as  a  remedy  by  Russian  peasants  in  dropsy  from 
time  immemorial.  The  fluid  extract  of  the  entire  plant 
(roots,  plants,  and  leaves)  seems  to  be  the  most  efficacious. 
It  can  be  given  in  doses  of  from  5  to  60  drops,  as  often  as 
every  four  hours.  Its  poisonous  effects  are,  however,  lia- 
ble to  show  themselves  after  a  certain  length  of  time,  and 
it  should  not  be  too  long  continued  uninterruptedly.  It 
is  less  liable  than  digitalis  to  develop  enfeebled  action 
of  the  heart.  The  active  principles  obtained  from  the 
plant  are  its  glucoside,  convallamarin,  and  the  alkaloid, 
majaline.  Their  strength  seems  about  that  of  digita- 
line.  Most  of  the  important  conclusions  relative  to  this 
plant  are  taken  from  the  observations  and  experiments 
of  Prof.  Germain  See  {Bulletin  General  cle  TJierapeic- 
tique^  etc.,  July  30,  1882).  So  much  has  appeared  with- 
in the  last  few  months  upon  this  plant,   that  I  must 


ACUTE  NEPHRITIS — TREATMENT — DIURETICS.      175 

refer  the  reader  to  some  of  the  numerous  articles  in  the 
medical  journals,  as  it  is  impossible  here  to  give  more 
details  even  with  reference  to  its  value  in  kidney  affec- 
tions. 

It  is  due  to  Parke,  Davis  &  Co.,  of  Detroit,  to  say  that 
we  in  the  United  States  were  for  a  long  time  indebted  to 
them  for  the  only  reliable  preparations  of  this  plant  that 
could  be  obtained. 

Scoparius  in  infusion  and  the  spirits  of  nitric  ether, 
although  experiments  have  recently  thrown  some  doubt 
upon  the  diuretic  properties  of  this  last  remedy,  are  of 
some  value  as  hydragogue  diuretics  ;  they  are  slightly 
stimulant  to  the  renal  circulation.  I  seldom  use  them, 
except  in  combination  with  other  remedies. 

All  the  above  may  be  regarded  as  pure  diuretics,  act- 
ing mostly  by  their  effect  upon  the  renal  circulation. 
They  do,  however,  increase  the  amount  of  solid  matter 
excreted.  Even,  as  is  shown  by  Bird,  ingestion  of 
simple  aerated  water,  by  creating  diuresis,  carries  away 
with  it  more  solid  matter  than  if  it  were  not  taken.  Thus 
the  simplest  hydragogues  do  act  in  a  greater  or  less 
degree  as  renal  depurants.  Dickinson'  gives  the  de- 
tails of  a  severe  case  of  acute  croupous  nephritis  aris- 
ing from  cold;  the  patient  "recovered  completely 
under  the  use  of  so  simple  a  diuretic  as  distilled  water. 
The  case  is  related  as  one  of  a  great  number  where  the 
same  result  had  followed  similar  measures." 

Still,  there  is  by  itself  a  class  of  important  diuretics 
which  act  directly  as  blood  and  renal  depurants.  I 
refer  to  such  of  the  alkalies  and  their  salts  as  are  capa- 
ble of  being  converted  in  the  system  into  carbonic  acid, 
as  the  acetate,  tartrate,  and  citrate  of  potash  and  soda. 
These  remedies  promote  diuresis,  probably  both  by 
their  stimulating  effect  upon  the  kidneys  and  by  en- 

'  Albuminuria,  p.  3ii4.    London,  1877. 


176  beight's  disease. 

dosmosis.  They  are  considered  to  aid  materially  in  tlie 
excretion  of  solid  matters  by  assisting  to  convert  into 
urea  and  uric  acid  various  substances  in  the  blood,  these 
substances  being  made  to  assume  such  a  diffused  and 
soluble  form  as  to  admit  of  ready  excretion.  Not  only 
after  their  use  are  the  urinary  salts  increased,  but  such 
extractive  matters  as  creatine,  creatinine,  and  uroxan- 
thin,  and  matters  rich  in  sulphur.  The  late  Dr.  James 
Hughes  Bennett  regarded  the  hitartrate  of  potash  as 
the  most  efficient  of  all  diuretics  in  Bright' s  disease, 
making  the  broad  statement  that  where  it  would  not 
act  he  seldom  found  anything  that  would. 

To  insure,  however,  the  diuretic  action  of  any  of  the 
above  salts,  the  specific  gravity  of  the  solutions  must  be 
less  than  that  of  the  blood  ;  that  is,  less  than  1028. 
According  to  Golding  Bird,  "The  proportion  of  solids 
dissolved  in  the  aqueous  vehicles  prescribed  being  al- 
ways less  than  five  per  cent."  The  well-known  theory 
of  endosmosis  and  exosmosis  makes  this  easily  explic- 
able, as  it  does  that  of  the  purgative  action  of  these 
salts  when  given  in  concentrated  solutions. 

Bennett  regarded  diuretics  indispensable  in  all  forms 
and  stages  of  nephritis,  and  when  the  form  of  nephritis 
is  such  as  to  demand  their  use,  I  believe  they  may 
always  be  used  in  some  form  or  strength. 

He  gives  the  details  of  two  very  remarkable  cases,' 
one,  croupous  nephritis,  in  a  man  aged  forty-nine,  of 
general  anasarca  and  ascites  ;  the  scrotum,  lungs,  legs, 
and  abdomen  were  all  filled  with  fluid ;  there  were  nu- 
merous renal  casts,  with  fatty  globules.  Various  dia- 
phoretic and  purgative  remedies  had  been  previously 
employed.  The  scrotum  had  reached  the  size  of  an 
adult  head. 

This  was  the  third,  but  by  far  the  most  severe,  attack 

'  Clinical  Lectures  on  the  Principles  and  Practice  of  Medicine. 


ACUTE   NEPHKITIS — TREATMENT — DIURETICS.      177 

the  man  had  had  ;  there  were  but  6  ounces  of  urine  daily ; 
breath  had  a  urinous  odor  ;  treatment  commenced  with 
digitalis  and  squills.  March  31st  to  May  9tli  the  treat- 
ment consisted  in  the  use  of  the  warm  bath,  the  adminis- 
tration variously  of  gin,  scilla,  and  digitalis,  spirits  nitric 
ether  and  Dover's  powders,  and  20-grain  doses  of  bi tar- 
trate of  potash,  with  the  effect  of  considerable  increase 
of  urine,  20  to  24  ounces  being  passed  daily ;  not  enough, 
however,  to  relieve  the  dropsy.  The  Dover's  powders 
perhaps  interfered  with  the  action  of  the  remedies,  as 
patients  with  nephritis  do  not  tolerate  even  small  doses 
of  opium.  May  9th  the  dose  of  the  bitartrate  was  in- 
creased to  30  grains  three  times  daily  ;  this  was  fol- 
lowed by  an  increase  of  urine  to  34  ounces.  May  15th, 
38  ounces ;  May  16th,  64  ounces,  and  May  23d,  128 
ounces  were  passed,  still  containing  albumin  in  consid- 
erable quantities ;  potash  constantly  continued.  May 
31st,  80  ounces,  perfectly  free  from  all  trace  of  albumin. 
From  this  date  convalescence  proceeded. 

The  second  case  was  one  of  acute  croupous  nephritis, 
characterized  by  ursemic  convulsions.  It  was  that  of  a 
man,  aged  thirty-six.  The  attack  was  contracted  Octo- 
ber 2d,  from  exposure  to  cold  and  wet ;  patient  ad- 
mitted to  the  hospital  October  25th.  There  was  oedema 
of  both  legs,  ascites,  and  general  anasarca  ;  highly  al- 
buminous urine  ;  tube  casts  and  blood  corpuscles  abun- 
dant ;  urine  scanty.  Digitalis  and  scilla  resorted  to 
without  benefit.  November  7th,  three  convulsions  of 
an  epileptiform  character,  with  foaming  at  the  mouth, 
each  of  almost  ten  minutes'  duration  ;  5  ounces  blood 
taken  by  cupping  from  over  kidneys,  and  bitartrate  of 
potash  3  j  ter  die,  given.  November  8th,  three  more 
fits,  with  great  drowsiness.  The  case  was  eventually 
cured  without  more  convulsions  by  the  continued  use 
of  bitartrate  of  potash. 

Dr.  Gfolding  Bird  endeavors  to   show,  from  a  table 

12 


178  beight's  disease. 

constructed .  by  Professor  Kranmer,  that  ' '  remedies 
wliich  exert  no  chemical  action  on  organic  matter  out 
of  the  body  appear  to  be  incapable  of  augmenting  the 
quantity  of  solids  in  the  urine,  and  hence  are  only  of 
use  in  increasing  the  elimination  of  water ;  they  may 
and  do  act  as  renal  hydragogues,  but  not  as  renal  de- 
purants,"  and  places  among  these  renal  hydragogues 
juniper,  Venice  turpentine,  broom,  squill,  digitalis, 
guaicum  and  colchicum,  lytta,  etc.  Actual  experience, 
however,  I  think,  shows  that  renal  hydragogues  do 
sometimes  act  as  renal  depurants,  and  increase  the 
quantity  in  the  urine  of  solid  excreta.  Dr.  Bird  thinks 
the  renal  depurants  to  be  such  as  increase  the  meta- 
morphosis of  tissue,  such  as  the  alkalies,  their  carbon- 
ates and  salts,  including  the  acetates,  tartrates,  citrates 
of  soda  and  potash. 

He  says  that  "as  a  result  of  this  view,  we  should 
expect  that  when  we  cause  an  alkaline  carbonate  to 
circulate  through  the  blood,  it  exerts  an  influence  on 
the  nascent  elements  of  those  matters  less  highly  in- 
fluenced by  life,  resembling  that  which  it  exerts  on 
dead  matter,  aiding  their  resolution  into  substances 
allied  to  those  produced  out  of  the  body,  and  actually 
causes  the  matter  to  assume  so  soluble  a  form  as  to 
allow  of  its  ready  excretion." 

He  has  certainly  shown  that  under  the  influence  of 
certain  alkaline  salts  the  solid  excreta  are,  in  health, 
greatly  increased.  He  considers  the  acetate  of  potash 
the  most  efficient.  I  have  used  it  with  benefit,  and  re- 
gard it  as  more  efficient  and  less  irritating  than  the 
nitrate.  In  the  selection  of  the  diuretic,  the  patho- 
logical condition  of  the  kidney  must  be  recognized  as 
accurately  as  possible. 

Saline,  and  indeed  all  diuretics,  are  apt  to  disappoint 
if  the  dropsy  and  conditions  of  the  kidney  are  alone 
considered  ;    if   the  action  of   the  heart  be  feeble,   or 


ACUTE   NEPHRITIS — TREATMENT — DIURETICS.      179 

there  be  defective  action  of  the  mitral  valves,  or  if  the 
portal  circulation  be,  as  it  often  is,  obstructed,  diuretics 
are  comparatively  inert ;  oedema  will  continue  to  exist, 
and  the  venous  circulation  of  the  kidney  remain  ob- 
structed. A  certain  activity  of  the  circulation  must  be 
brought  about  for  the  saline  diuretic  to  find  admission 
into  the  vessels.  Once  admitted  into  the  circulation,  the 
epithelia  of  the  renal  tubules  are  incited  to  additional 
activity  to  absorb  them,  the  new  substances  in  these 
tubules  producing,  according  to  Beale,  a  temporary 
blocking,  leading  to  over-fulness  and  increased  pres- 
sure of  the  corpora  Malpighiana,  consequently  an  addi- 
tional pouring  out  of  water,  washing  away  the  contents 
of  the  tubule  ;  this  process  repeating  itself  continually. 

The  correctness  of  the  theories  of  Beale  and  Bird  in 
regard  to  the  physiological  action  of  the  saline  diuretics 
in  forming  new  excrementitious  material  in  the  tubules 
is  not  easy  of  demonstration,  but  the  views  of  these 
authors  are  of  sufficient  interest  to  refer  to. 

The  muriate  of  iron,  when  the  action  of  the  heart  is 
feeble,  in  combination  with  digitalis  will  add  greatly  to 
the  power  of  the  latter.  When  the  liver  is  deranged  or 
inactive,  the  integrity  of  its  functions  must  first  be  re- 
stored. Bird,  quoting  from  Dr.  Barlow,  gives  the  fol- 
lowing aphorism  with  regard  to  the  entrance  of  remedies 
into  the  renal  circulation  : 

"If  a  sufficient  quantity  of  water  cannot  be  received 
into  the  small  intestines,  or  the  circuit  through  the 
portal  system  in  the  vena  cava  ascendans,  or  thence 
through  the  lungs  and  heart  into  the  systemic  circula- 
tion, be  obstructed,  or  if  there  be  extensive  disorganiza- 
tion of  the  kidneys,  the  due  secretion  of  urine  cannot 
be  effected." 

Counter-irritants  over  the  region  of  the  kidneys  have 
been  considered  of  value.  Grainger  Stewart  gives  the 
details  of  a  case  of  acute  albuminuria,  produced  by  cold, 


180  beight's  disease. 

in  which  albnmin,  blood,  and  casts  persisted  for  several 
weeks,  and  which  was  finally  cured  by  the  external  use 
of  croton  oil  liniment,  and  afterward  pure  croton  oil,  over 
the  lumbar  region,  the  albuminuria  rapidly  disappear- 
ing after  a  copious  rash  had  been  produced.  He  also 
gives  several  other  cases  which  appear  to  have  been 
benefited  by  this  treatment,  and  regards  inunction  with 
croton  oil  as  one  of  the  most  important  means  of 
diminishing  the  secretion  of  albumin.  I  have  never 
employed  counter-irritation  in  acute  nephritis,  and  am 
skeptical  as  to  any  benefit  to  be  derived  from  it ;  never- 
theless, by  drawing  to  the  surface  some  of  the  blood 
which  would  otherwise  be  thrown  into  the  renal  artery, 
it  might  do  good.  The  use  of  croton  oil  is,  however, 
inconvenient  and  annoying.  On  the  same  principle 
Paquelin's  therm o- cautery,  the  proper  use  of  which  is 
not  attended  with  much  pain,  should  be  of  value.  Of 
the  benefit  of  diuretics  applied  locally,  as  the  infusion 
of  digitalis  or  scoparius,  on  spongio-piline,  or  poultices, 
I  have  not  much  opinion,  as,  though  possibly  useful, 
they  are  troublesome  of  application.  Diuresis  can  be 
more  easily  produced  by  other  means. 

Local  abstraction  of  blood  has  been  thought  useful 
by  several  writers.  I  cannot  agree  with  Dr.  G.  John- 
son, who  explains  the  benefit  derived  from  it  by  the 
theory  that,  by  the  abstraction  of  a  few  ounces  of  blood 
from  the  loins,  we  relieve  renal  congestion  and  thereby 
lessen  the  destruction  of  blood  constituents  which  re- 
sults from  contamination  of  blood  by  urinary  excreta. 
Dr.  Johnson  is  inclined  to  make  all  theories  conform  to 
his  belief  that  nephritis  is  always  the  result  of  the  local 
irritation  of  the  blood-vessels  of  the  kidney  by  contam- 
inated blood.  The  explanation  which  he  gives  farther 
on  is  more  rational,  namely  :  "The  lumbar  arteries, 
which  supply  the  integuments  of  the  loins,  arise  from 
the  abdominal  aorta,  close  by  the  origin  of  the  renal 


ACUTE  NEPHRITIS — TREATMENT.  181 

arteries ;  and  when  leeclies  or  cupping-glasses  draw 
blood  through  the  skin  of  the  back,  it  is  certain  that 
the  diminished  pressure  within  the  lumbar  arteries  will 
divert  a  certain  quantity  of  blood  from  the  neighboring 
renal  arteries.  The  same  principle  explains  the  good 
effects  of  leeching  in  cases  of  pericarditis." 

Dry  cupping,  according  to  the  same  author,  "  acts  in 
a  somewhat  similar  way  to  hot  fomentations.  It  draws 
an  abundance  of  blood  through  the  arteries  into  the 
subcutaneous  capillaries,  which,  when  the  cups  are  re- 
moved, returns  through  the  veins  to  the  heart."  He 
does  not  resort  to  the  local  abstraction  of  blood  except 
in  cases  of  threatened  or  existing  head  trouble  from 
ursemic  poisoning. 

The  cliloride  of  iron  has  been  of  invaluable  service  to 
me  in  aiding  to  diminish  the  excretion  of  albumin,  either 
alone,  or  in  combination  with  digitalis,  where  there  has 
been  feebleness  of  the  heart's  action.  I  have  never  used 
it  in  the  early  periods  of  acute  nephritis  characterized 
by  vascular  erethism,  but  have  confined  its  employment 
to  cases  of  nephritis  where  the  acute  symptoms  had 
subsided.  In  such  cases  I  have  known  it,  without  the 
aid  of  any  other  remedies,  to  cure  the  albuminuria 
entirely. 

An  instance  illustrative  of  its  efficacy  in  combination 
with  cantharides  is  given  in  Case  VI.  It  acts  probably 
by  increasing  muscular  contractility  and  force  of  the  ar- 
terial circulation.  At  all  events,  it  has  decided  diuretic 
properties,  while  it  is  of  great  use  in  restoring  some  of 
the  wasted  elements  of  the  blood.  It  probably  increases 
oxydation  by  the  epithelia  by  adding  to  the  oxygen  of 
the  blood  corpuscles,  but  its  efiicacy  depends  mainly 
and  intrinsically  upon  its  stimulating  effect  upon  the 
nervous  system. 

Dr.  Hassel,  in  the  London  Lancet,  December  31,  1864, 
has  an  interesting  article  relative  to  the  modus  operandi 


182  beight's  disease. 

of  the  chloride  of  iron.  Its  astringent  properties  count 
for  nothing  in  nephritis.  The  pliospJiate  of  iron  is  in 
some  cases  equally  efficacious. 

Ergot,  from  its  known  power  in  producing  arterial 
pressure  and  contraction  of  the  blood-vessels,  might  be 
expected  to  be  of  decided  use  in  passive  congestion  of 
the  renal  vessels,  and  should  be  a  valuable  accessory 
in  diminishing  albuminous  exudation.  Nevertheless,  in 
the  few  cases  in  which  I  have  used  it  I  have  derived  no 
benefit  from  it — no  more  than  from  its  alkaloid,  esserine. 
A  more  extensive  trial  of  it,  perhaps  in  large  doses  or 
in  combination  with  iron  or  digitalis,  may  be  followed 
by  more  favorable  results. 

Fuchsin  and  rosanilin  have  been  reported  by  Drs. 
Feltz  and  Bouchet '  as  having  in  a  number  of  cases  been 
efficacious  in  producing  the  cessation  of  albuminous  ex- 
cretion. They  administered  it  either  in  a  pill  or  mixture, 
three  grains  being  given  daily.  They  claim  these  color- 
ing matters  to  be  well  borne  by  the  system,  and  to  be 
comparatively  harmless.  Prof.  E,  di  Renzi,^  of  Genoa 
(quoted  by  Tyson),  has  more  recently  published  the 
treatment  by  fuchsin.  He  found  it  efficacious  in  di- 
minishing the  quantity  of  albumin.  He  administered 
it  in  doses  of  from  3.8  grains  to  38.5  grains  in  the 
twenty-four  hours.  He  states  that  unless  it  colors  the 
urine  it  does  not  diminish  the  albumin.  I  have  found 
both  these  remedies  of  value  in  preventing  the  excretion 
of  albumin. 

Gallic  acid  I  have  sometimes  found  of  benefit  in  a 
number  of  cases  of  prolonged  albuminuria  following 
acute  croupous  nephritis,  after  the  acute  symptoms  and 
dropsy  and  oedema  had  disappeared.  In  the  case  of  a 
child  who  had  recovered  from  malignant  scarlet  fever, 


1  Deutsch.  Med.  Wochensclir. ,  1879. 

2  Vircliow's  Archiv,  vol.  Ixxx.,  p.  510. 


ACUTE  ISTEPHEITIS — TEEATMENT.  183 

and  who  had  suffered  from  diphtheria,  acute  croupous 
nephritis,  anuria,  and  convulsions,  the  albuminuria  was 
persistent,  in  spite  of  all  remedies,  even  after  all  other 
symptoms  had  disappeared.  It  yielded  rapidly  to  the 
administration  of  gallic  acid,  three  or  four  grains  being 
given  three  times  daily.  Together  with  the  diminution 
of  albumin  the  amount  of  urine  increased.  I  do  not 
proffer  any  explanation  of  its  modus  operandi^  other 
than  by  its  contractile  effects  upon  the  renal  blood-ves- 
sels. It  perhaps  thus  causes  increased  pressure  in  the 
Malpighian  tuft,  favorable  to  the  flow  of  water  and  un- 
favorable to  the  excretion  of  albumin.  Astringent  rem- 
edies, in  checking  albuminuria,  are,  however,  generally 
disappointing  and  not  to  be  relied  upon. 

The  tannate  of  sodium  I  have  recently  used  with  great 
benefit  in  diminishing  dropsy  and  anasarca  and  albu- 
minous exudation.  It  undoubtedly  possesses  some  diu- 
retic properties  due  probably  to  the  soda,  while  the  tan- 
nic acid  may  act  in  the  same  manner  as  gallic  acid  in 
diminishing  albuminuria.  I  have  prescribed  it  in  doses 
of  10  to  20  grains,  three  or  four  times  daily  ;  it  is  best 
administered  well  diluted  in  water,  though  it  might  be 
given  in  the  form  of  pills.  I  regret  that  I  am  not  able 
to  state  fully  the  authority  that  first  induced  me  to  try 
this  remedy.  I  find  simply  a  note  that  I  had  made 
from  some  medical  Journal,  to  the  effect  that  "  it  was 
said  by  Prof.  Pribram  to  be  a  verj^  efficient  diuretic,  and 
useful  in  dropsies  from  nephritis." 

HhQ  nitrite  of  glycerine  (nitro-glycerine,  glonoine)  was 
first  recommended,  I  believe,  in  nephritis  by  Dr.  A.  Mayo 
Robson.'  He  gives  some  extraordinary  results  derived 
from  its  use,  and  I  think  them  of  sufficient  importance 
to  present  a  brief  abstract  of  the  cases  he  reports  : 

'  The  Use  of  Nitro-glycerine  in  Acute  and  Chronic  Briglit's  Disease,  and 
in  the  Vascular  Tension  of  the  Aged  :  British  Medical  Journal,  November, 
1880. 


184  beight's  disease. 

Case  I. — A  man,  aged  fifty-sis.  Had  clitonie  (croupous,  evidently) 
nepliiitis  for  two  years.  CEdema,  anasarca,  and  hypertrojiliied  heart. 
Urine  highly  albuminous — specific  gravity,  1008;  24  oz.  j)assed  in 
twenty -four  hours.  One  minim  of  one  per  cent,  solution  nitro- glyce- 
rine given  every  half  hour ;  after  increasing  dose  to  1^  iij.  ter  in  die, 
urine  increased  to  three  pints  daily ;  albumin  diminished.  All  symp- 
toms relieved ;  remedy  suspended  for  a  few  days ;  the  symptoms  re- 
turning, the  use  of  the  remedy  was  followed  by  the  same  benefit. 

Case  III. — ^A  woman,  aged  fifty-two.  In  June  hftd  an  attack  of  aj)o- 
plexy  followed  by  paralysis.  Urine  normal  in  quantity;  specific 
gi-avity,  1006 ;  trace  of  albumin,  great  vascular  tension.  In  August, 
as  symptoms  of  paralysis  were  returning,  nitro-glycerine,  TTL  j.  ter  die, 
was  prescribed.  Vascular  tension  at  once  reduced;  specific  gravity 
rose  to  1012.     Symptoms  entirely  relieved. 

Case  rV. — Woman,  aged  fifty.  Angina  pectoris,  asthma,  and  slight 
hy|3ertrophy  of  heart.  Pulse  hard  and  tense.  Specific  gTavity  mine, 
1005.  Glonoine,  Tfl^j.  ter  die.  Tension,  pain,  and  asthma  all  re- 
lieved. 

Case  V. — An  adult.  (Acute  croupous  hemorrhagic  nephritis.)  At- 
tack came  from  taking  cold.  Urine,  16  oz.  in  twenty  four  hours,  thick, 
smoky,  highly  albuminous,  containing  renal  epithelia,  casts,  blood, 
and  lithates.  Diaphoretics,  rest  in  bed,  milk  diet,  and  alkalies  em- 
ployed. At  the  end  of  twenty  days,  no  better.  Sattuxlay  night  glo- 
noine given,  Tfl_  j.  every  four  hours ;  the  nest  day  the  mine  increased 
to  28  oz.,  less  blood  and  albumin.  Monday,  no  blood;  very  little  al- 
bumin. The  Saturday  following  urine  was  normal.  No  relapse  oc- 
curred. 

Case  VI. — ^Man,  aged  thirty-nine.  Acute  hemorrhagic  croupous  ne- 
phritis from  cold.  Symptoms  and  conditions  veiy  similar  to  Case  V. 
At  the  end  of  three  days  no  better  (urine  loaded  with  blood) ;  glo- 
noine, TTLj.  every  four  hours.  In  twenty-foiu'  hoiirs  blood  disappeared. 
Urine  increased  from  20  oz.  to  3  pints.  In  six  days  wa§  well.  Had  a 
relapse,  which  yielded  in  its  turn  to  nitro-glyceiine. 

Case  VIII. — Woman,  aged  sisty-five.  Acute  croupous  nephritis  with 
hronchitis.  Pulse  tense.  Urine  smoky,  containing  blood  albumin, 
abundant  casts,  and  renal  epithelia.  Diaphoretics  and  dim'etics  use- 
less. Nitro-glycerine  eveiy  three  hom-s,  in  twenty-four  hours  the  dose 
being  increased  to  TTl,  jss.  doses.  Urine  increased.  Less  blood  and 
albumin.  This  remedy  being  suspended,  the  conditions  became  as 
bad  as  before,  but  were  promptly  relieved  again  by  the  glonoine. 


ACUTE   NEPHEITIS — TREATMENT.  185 

Tliougli  nitro-glycerine  seems  to  produce  mucli  the 
same  physiological  effect  as  amyl  nitrite,  its  effects  are 
more  lasting,  and  it  is  easier  of  administration.  Dr. 
Robson  observes  :  "Whether  due  to  chronic  kidney  dis- 
ease or  arterial  fibrosis,  this  condition  is  unquestionably 
relieved  by  nitro-glycerine,  and  v^ith  diminution  of  pres- 
sure improvement  follows." 

According,  however,  to  the  experiments  of  Goll  and 
Stokvis  and  Overbeck,'  arterial  pressure  alone,  without 
diminished  rapidity,  produces  polyuria,  but  not  albu- 
minuria. For  the  production  of  the  latter  there  must 
be  diminished  rapidity  of  the  renal  circulation,  with  or 
without  increased  pressure,  and  for  the  production  of 
oliguria  and  albuminuria,  there  must  be  diminished 
pressure  and  rapidity.  It  does  not  seem  easy  to  recog- 
nize, therefore,  the  manner  in  which  diminished  tension 
increases  the  flow  of  urine.  In  the  cases  described  by 
Dr.  Robson  there  must  have  existed  diminished  pressure 
and  rapidity  to  produce  scanty  and  albuminous  urine, 
and  to  bring  about  increased  flow  of  urine  without  albu- 
min, increased  pressure  and  swiftness  of  the  renal  circu- 
lation must  have  been  produced  by  the  nitro-glycerine, 
and  this  may  have  been  effected  by  relieving  the  vaso- 
motor spasm,  which  must  cause  slowness  and  diminished 
pressure.  This  theory  (I  cannot  call  it  explanation)  is 
doubtless  insuflB.cient,  but  at  present  I  am  not  able  to 
offer  another. 

The  remedy  may  act  through  the  renal  ganglia  en- 
tirely, and  it  is  possible  that  it  is  through  this  plexus 
that  the  curative  effects  of  many  drugs,  such  as  this  and 
aurum,  depend. 

I  have  not  employed  as  yet  this  remedy  in  acute  ne- 
phritis, simply  for  the  reason  that  I  have  found  other 
and  tried  appliances  of  treatment  sufficient,  and  have 


'  See  Cliarcot :  Le9ons  sur  I'Albuminurie. 


186  beight's  disease. 

not  thus  far,  since  the  article  was  published,  experienced 
a  necessity  of  resorting  to  it. 

A  remarkable  case  of  polyuria,  with  hard  tense  pulse, 
which  recently  came  under  my  care,  was  greatly  re- 
lieved by  this  remedy.  The  patient  was  a  man,  forty- 
five  years  old,  who  was,  without  any  preceding  symp- 
toms of  ill  health,  suddenly  seized  with  violent  thirst 
and  constant  desire  to  urinate,  passing,  for  about  three 
weeks,  24  quarts  daily,  by  measurement,  of  colorless 
urine  (specific  gravity  998  to  1003).  The  sulphate  of 
iron,  3  grains  ter  die,  brought  about  a  reduction  of  the 
quantity  to  12  quarts.  The  use  of  gionoine,  gtt.j.  of  a 
one  per  cent,  mixture  four  times  daily,  was  followed 
by  a  diminution  of  the  quantity  to  6  quarts  daily.  This 
case  is  alluded  to  again  in  Chapter  XXIII.,  but  I  men- 
tion it  here  to  show  that  the  drug  can,  under  certain 
circumstances,  relieve  conditions  oj)posite  to  those  de- 
scribed by  Dr.  Robson.  The  relief  in  this  case  is,  how- 
ever, more  easily  explicable,  the  polyuria  being,  no 
doubt,  in  part  due  to  increased  pressure  and  swiftness 
of  the  blood-current  in  the  renal  vessels. 

The  doses  recommended  by  Dr.  Robson  cannot,  how- 
ever, be  tolerated  by  all  constitutions.  I  have  known  a 
hundredth  of  a  drop  to  produce  great  fulness  and 
throbbing  and  pain  of  the  cerebral  vessels,  and  I  should 
prescribe  very  cautiously,  if  at  all,  a  minim  every  half 
hour,  'as  given  by  Dr.  Robson  in  Case  I.  It  should  be 
noted,  however,  that  the  minim  doses  above  mentioned 
refer  to  a  one  per  cent,  solution. 

I  shall  now  consider  several  remedies  with  which 
alone,  or  in  combination  with  other  remedies  and  meas- 
ures of  treatment,  many  cases  of  acute,  and  some  even 
of  chronic  nephritis  have  been  cured,  the  details  of  a 
number  of  which  I  shall  give.  First  among  these  I 
place,  facile  princeps.,  Tiydrargyri  cliloridum  corrosi- 
T)um  and  liydrargyri  cltloride  mite. 


ACUTE   NEPIIRITIS^TREATMENT.  187 

My  experience  lias  led  me  to  employ,  usually,  the 
mild  chloride  in  interstitial  nephritis  and  the  corrosive 
sublimate  in  croupous  nephritis.  In  some  cases,  with- 
out being  able  to  tell  wh}^,  I  have  found  benefit  to  be 
derived  only  from  the  opposite  course.  I  am  accus- 
tomed to  give  the  former  prepared  by  combining  or  trit- 
urating 1  part  of  the  drug  with  99  parts  of  sugar  of 
milk,  this  being  an  inert  vehicle,  the  adult  dose  being 
5  to  10  grains  every  two  or  three  hours,  taking  care  not 
to  give  it  in  such  doses  as  to  aifect  the  gums  or  to  relax 
the  bowels.  Of  corrosive  sublimate  I  use  a  preparation 
of  1  part  of  the  crude  drug  to  10,000  of  sugar  of  milk  ; ' 
giving  8  to  10  grains  at  the  same  intervals  as  the  proto- 
chloride.  The  numerous  triturations  and  tablet  tritu- 
rates that  have  recently  come  into  use  and  are  kept 
by  leading  druggists,  as  calomel,  corrosive  sublimate, 
arsenic,  etc.,  greatly  simplify  the  administration  of 
small  doses.  The  tablet  triturates,  containing  one  hun- 
dredth of  a  grain  of  corrosive  sublimate,  are,  however, 
an  unnecessarily  large  and  even  dangerous  dose  in 
acute  nephritis. 

I  know  that  the  possible  effect  of  such  small  doses 
will  be  regarded  by  many  with  incredulity,  but  their 
value  has  been  demonstrated  too  frequently  for  it  to  be 
doubtful,  and  the  recognition  of  the'  efficacy  of  these 
doses  is  inevitable,  as  it  is  a  matter  of  simple  and  as- 
sured truth.  The  experience  of  medical  men  of  ac- 
knowledged experience  and  ability  is  rapidly  tending 
to  show  that  very  minute  doses  of  medicine  accomplish, 
in  numerous  conditions,  more  than  ponderous  or  even 
moderate  doses.  Particularly  is  this  shown  in  those 
cases  in  which  the  dual  action  of  drugs  is  manifest,  as 
in  the  action  of  corrosive  sublimate  upon  the  kidneys  in 
health  and  in  disease. 

'  Ten  grains  would  contain  a  tliousandtli  of  a  grain  of  the  drug. 


188  bright' S   DISEASE. 

Administered  in  these  small  doses  it  is  not  necessary 
to  "guard"  calomel  by  opium,  which  drug  is,  in  ne- 
phritis, very  injurious  ;  nor  are  its  defibrinating  and 
deleterious  effects  produced  as  when  given  in  officinal 
doses,  but  it  can  be  administered  to  anaemic,  delicate, 
and  even  scrofulous  systems,  and  in  adynamic  con- 
ditions. Since  calomel  is  of  undoubted  use  in  control- 
ling inflammations  of  mucous  and  serous  membranes,  as 
enteritis,  pleuritis,  peritonitis,  iritis,  etc.,  and  inflam- 
matory conditions  of  the  lungs  and  liver  characterized 
by  plastic  effusions,  there  is  no  reason  why  it  may  not 
produce  analogous  benefit  in  affections  of  the  paren- 
chymatous structure  and  of  the  connective  tissue  of 
the  kidney.  This  may  seem  a  coarse  proposition,  but 
it  is  at  least  not  a  baseless  one.  To  endeavor  to  show 
how  mercury  acts  as  an  antiphlogistic  would  involve 
the  consideration  of  numerous  theories,  and  much  space. 
That  it  has  antiphlogistic  powers  in  affections  of  the 
above-named  tissues,  clinical  experience  abundantly 
shows.  Whatever  creeds  practitioners  hold,  and  upon 
whatever  theories  they  may  practice,  mercury  will  al- 
ways, in  the  opinion  of  the  experienced  physician,  retain 
something  of  the  high  rank  it  has  for  ages  enjoyed  in 
the  treatment  of  certain  kinds  of  inflammation. 

It  is  not  sufficient  always  to  rely  exclusively  on  either 
of  these  two  remedies,  even  where  they  seem  especially 
appropriate.  In  anuria  or  dropsy,  the  hot-air  bath  or 
the  wet  sheet  or  vapor  bath  should  be  resorted  to,  and 
the  recumbent  position  enjoined.  Under  the  use  of  one 
of  the  above  mercurials,  in  acute  nephritis  I  have  re- 
peatedly found  the  albumin,  blood,  and  oedema  to  dis- 
appear so  rapidly  as  to  leave  no  doubt  as  to  the  con- 
nection of  cause  and  effect. 

It  has  already  been  shown  that  an  exclusively  intersti- 
tial or  croupous  nephritis  does  not  exist,  but  that  while 
the  epithelia  or  connective  tissue  may  be  mainly  affected, 


ACUTE  NEPHRITIS — TREATMENT.  189 

the  inflammation  must  in  some  degree  affect  both.  I 
think  that  in  determining  which  of  the  two  mercurials 
to  employ  a  proper  diagnosis  is  necessary,  inasmuch 
as  I  believe  the  mild  chloride  of  mercury  in  acute  inter- 
stitial nephritis  to  be  almost  as  useful  as  in  enteritis  or 
pleuritis.  In  croupous  nephritis  I  believe  it  to  be  less 
useful ;  here  I  think  corrosive  sublimate  the  more  valu- 
able. Still,  without  being  able  to  tell  why,  I  have 
sometimes  found  the  latter  of  most  use  in  interstitial 
nephritis.  I  consider  its  action  not  dissimilar  to  that 
of  calomel  in  the  same  class  of  affections,  as  in  pneu- 
monia, enteritis,  and  pleuritis. 

It  is  a  matter  of  no  slight  interest  to  consider  that 
while  corrosive  sublimate,  alone  or  in  conjunction  with 
other  remedies,  will  often  correct  pathological  condi- 
tions characterized  by  the  secretion  of  albumin,  bloody 
urine  or  suppression  of  urine,  the  same  remedy  taken  in 
health,  in  toxic  doses,  often  produces  these  very  condi- 
tions. I  do  not  propose  to  descant  upon  the  merits 
of  any  theory,  still  less  to  support  any  supposed  law  of 
cure,  but  simply  to  present  facts.  In  acute  croupous 
nephritis  we  have  cloudy  swelling  of  the  epithelia  and 
increased  bulkiness,  with  the  development  from  the 
epithelia  of  inflammatory  and  pus  corpuscles  and  de- 
struction of  the  epithelia  ;  there  is  plastic  exudation 
and  often  exudation  of  blood-cells  ;  the  corpora  Mal- 
pighiana  become  also  the  seat  of  inflammation  ;  and, 
as  a  result  of  these,  other  changes,  albuminuria  and 
anuria,  ensue. 

Now  corrosive  sublimate  may  produce  changes  very 
similar  to,  if  not  identical  with,  the  above.  Orfila  and 
Christison  show  that  the  kidneys  are  much  inflamed 
after  poisoning  by  this  drug,  scanty  and  frequent  mic- 
turition occurring.  Taylor  ("  On  Poisons  ")  gives  an  ac- 
count of  several  cases  of  poisoning  by  it,  in  which  there 
was  suppression  of  urine  for  several  days.     The  general 


190  beight's  disease. 

symptoms  described  are  such  as  occur  in  acute  croup- 
ous nephritis.  The  fullest  account  I  have  met  with  of 
its  effects  upon  the  kidneys  is  given  by  Allen/  taken 
from  authentic  sources.  Among  the  effects  mentioned 
may  be  cited  the  following :  "  Blackish  albuminous 
urine ;  scanty  urine ;  bloody  urine  ;  anuria  for  five 
days  ;  ischuria.  Under  the  microscope  the  urine  pre- 
sented granular,  fatty  tubuli  in  large  numbers,  showing 
on  their  surface  epithelial  cells  of  the  tubuli  uriniferi ; 
also  in  a  state  of  granular  fatty  degeneration."  (The 
last,  OUivier,  from  Tardieu  ;  effects  of  1.1  gramme.) 

Of  cantharides  as  a  diuretic  I  have  already  spoken  ; 
but  I  have  also  found  it  useful  given  in  the  same  doses 
as  the  two  above  mercurials  in  acute  croupous  ne- 
phritis with  diminished  or  suppressed  urine.  I  have 
often  found  it  of  use  in  alternation  with  the  mercurials, 
the  result  being  diminished  albuminuria  and  increased 
urine,  that  result  being  attained  when  neither  mercurial 
would  produce  it.  I  give,  however,  very  minute  doses, 
about  the  same  strength  as  of  the  bichloride. 

Here  again  I  will  not  present  any  attempt  at  explana- 
tion of  the  modus  relevandi,  simply  stating  that  the 
toxic  effects  of  cantharis  are  similar  to  the  phenomena 
met  with  in  acute  croupous  nephritis,  as  albuminous 
urine,  anuria,  blood  casts,  etc. 

Cornil,  in  his  researches  upon  the  effects  of  canthari- 
dine  upon  the  kidneys,  finds  similar  lesions  in  the  glo- 
meruli and  in  Bowman' s  capsule,  and  the  same  changes 
in  the  tubules  as  occur  in  acute  or  subacute  croupous 
nephritis,  even  to  the  existence  in  the  tubules  of  casts. 
He  states  that  "it  would  be  impossible,  for  example,  to 
distinguish  a  preparation  of  a  kidney  of  a  dog  suffering 
from  subacute  poisoning  by  cantharidine,  from  a  prepa- 
ration of  the  kidney  of  a  child  who  had  died  from  diph- 

'  Encyclopaedia  of  Pure  Materia  Medica.     New  York,  1874. 


ACUTE   NEPHRITIS — TREATMENT.  191 

theria  with  albuminuria."  He  considers,  in  poisoning 
by  cantliaridine,  that  "  the  essential  phenomena  occur 
in  the  cavity  of  the  glomerulus  and  in  the  renal  tubules. 
The  lesion  of  the  connective  tissue,  which  exists  in  this 
case,  is  quite  of  minor  importance." 

Nitric  acid  alone,  or  in  conjunction  with  the  proto- 
chloride  or  bichloride,  I  have  sometimes  found  of  great 
service  in  diminishing  the  excretion  of  albumen,  and  in 
anasarca,  or  even  in  dropsical  effusions.  Works  on 
materia  medica  generally  furnish  no  special  indications 
for  its  use  in  albuminous  or  nephritic  affections.  That 
it  is  a  stimulant  and  astringent  is  recognized,  and  it 
may  thus  act  in  the  same  wa}^  as  the  chloride  of  iron. 
It  certainly,  in  conjunction  with  the  two  mercurials, 
often  promotes  diuresis  in  acute  or  subacute  nephritis. 
Dr.  Joseph  Kidd  {Practitioner,  August,  1882)  says, 
relative  to  its  use  in  chronic  nephritis  :  "In  the  treat- 
ment of  granular  degeneration  of  kidneys,  the  gout 
kidney  par  excellence,  I  can  speak  with  much  confidence 
of  the  good  effects  of  nitric  acid.  In  many  phases  of 
the  disease,  especially  when  the  urine  is  very  pale,  of 
low  specific  gravity,  and  highly  acid,  with  nausea^  ano- 
rexia, furred  tongue,  it  suits  when  iron  and  quinine  dis- 
agree. It  exerts  a  specific  action  on  the  urine,  causing 
the  turbid  to  become  clear,  and  at  times  it  does  the  op- 
posite, causing  the  pale  clear  urine  to  become  turbid 
and  dark-colored.  It  also  relieves  the  gout  pains  in  the 
joints  incidental  to  the  disease." 

An  example  of  its  eflEiciency  in  conjunction  with  calo- 
mel, in  acute  croupus  nephritis  with  hydrothorax,  is 
shown  in  Case  III. 

Mtric  acid  has  always  been  regarded  by  homoeopathic 
physicians  as  a  valuable  remedy  in  affections  of  the 
urinary  system.  I  am  unable  to  see,  however,  from 
their  materia  medica,  that  it  seems  especially  applicable 
to   the  conditions   that  obtain   in  nephritis,  except  in 


192  beight's  disease. 

tlie  symptoms  mentioned  as  polyuria  and  increased  fre- 
quenc}^  of  urination.     It  does  not,  hov/ever,  like  corro- 
sive sublimate  and  cantharis,  produce  a  specific  conges- 
tion or  inflammation  of  the  kidney. 
I  administer  it  usually  in  the  following  doses  : 

Acidi  nitrici  puri 3  ss. 

Aquae  dest |  ss. 

Three  to  six  drops  three  times  daily. 

Dilute  phosphoric  acid  has  also  proved  of  value, 
particularly  after  the  subsidence  of  the  most  acute 
symptoms,  in  lessening  and  even  controlling  the  albu- 
minous secretion.  I  can  explain  its  utility  only  by  the 
same  theory  I  have  adduced  relative  to  the  action  of 
nitric  acid. 

Arsenic  (arsenious  acid)  is  a  remedy  from  which  bene- 
fit is  sometimes  derived  in  nephritis.  That  it  should 
produce  some  efi'ect  in  nephritis  is  evident  from  its  ac- 
tion upon  the  kidneys  when  taken  in  poisonous  doses. 
It  then  may  produce  scanty,  bloody,  and  albuminous 
urine,  and  suppression  of  urine.  Yirchow's  "  Archiv," 
Bd.  xxxiv.,  p.  213,  contains  the  account  of  the  case  of 
a  boy  poisoned  by  arsenic,  whose  kidneys  were  found 
profoundly  affected  by  it.  "The  cortical  tubules  were 
opaque  and  finely  granular,  and  their  epithelia  could 
not  be  isolated." 

According  to  H.  C.  Wood,'  there  is,  "in  arsenical 
poisoning,  a  wide-spread  fatty  degeneration  of  the  tis- 
sues," and  in  another  case,  quoted  from  Dr.  Saikowsky, 
in  Yirchow's  "Archiv,"  Bd.  xxxiv.,  p.  77,  the  kidneys 
were  fatty,  "  their  tubes  choked  up  with  fat  globules, 
their  epithelia  almost  completely  destroyed."  Accord- 
ing to  Dr.  S.  Weir  Mitchell,  the  anasarca  produced  by 
repeated  doses  of  arsenic  may  be  preceded  or  accom- 


'  Therapeutics,  Materia  Medica,  and  Toxicology. 


ACUTE   NEPHRITIS — TREATMENT.  193 

panied  by  the  presence  of  albumin  and  of  tube  casts,  as 
in  nephritis. 

Certainly  many  of  the  symptoms  and  pathological 
conditions  which  are  found  in  the  arsenic  cachexia  are 
reproduced  by  nephritis.  Among  these  may  be  enu- 
merated pallor,  exhaustion,  anaemia,  anasarca,  nausea, 
thirst,  and  neuralgic  pains  in  various  parts  of  the  body. 

I  have  found  benefit  from  its  use  in  only  a  few  in- 
stances, one  a  case  which  occurred  in  a  young  man 
twenty  years  of  age  (see  Case  XY.),  of  chronic  croup- 
ous nephritis,  the  result  of  cold,  accompanied  by  nausea 
and  anasarca.  The  treatment  consisted  exclusively  of 
Fowler's  solution,  five  drops  being  given  three  times 
daily,  and  the  administration  of  drachm  doses  of  the 
tincture  of  cinchona.  The  cure  was  complete.  I  have 
not  been  willing,  however,  to  rely  upon  it  in  acute  con- 
ditions, but  have  employed  it  after  the  subsidence  of 
these.  Homoeopathic  practitioners  report  many  cases 
of  its  beneficial  effects ;  one  noticeably  in  the  All.  Ho- 
meopath. Zelt'ung,  No.  68,  p.  158,  in  which  nephritis, 
consequent  upon  scarlatina,  with  ascites,  hydrothorax, 
oedema  pulmonum,  scanty,  bloody,  and  albuminous 
urine,  was  cured  by  it. 

Helonias  dioica  (unicorn  plant)  has  been  thought  to 
be  curative  in  some  cases  of  nephritis,  as  well  as  I  can 
judge  from  the  details  given,  the  cases  being  subacute 
nephritis,  one  case  being  in  connection  with  pregnancy, 
attended  with  convulsions.  Under  certain  circumstances 
this  plant  has  undoubtedly  some  diuretic  properties. 
Prof.  S.  A.  Jones,  of  the  University  of  Michigan,  has 
shown  that  it  will  render  alkaline  urine  acid.  I  have 
not  employed  it,  and  cannot,  therefore,  judge  of  its 
value. 

Apis  mellifica  is  considered  by  many  homoeopathic 
and  by  other  physicians  a  remedy  of  great  value  in 
acute  and  chronic  nephritis.     Many  cases  are  cited  lUus- 

13 


194  bright' S   DISEASE. 

trative  of  its  supposed  utility,  which  I  will  not  quote. 
I  have,  however,  derived  myself  so  little  benelit  from  it, 
that  I  am  not  disposed  to  employ  it  in  severe  cases. 

Euonymus  Atropurpureus. — Dr.  Wm.  H.  Holcombe, 
of  New  Orleans,  describes  several  cases  in  which  he  used 
with  perfect  success  euonymine,  the  alkaloid  of  euony- 
mus ("wahoo").  The  first  was  that  of  a  young  man 
affected  with  chronic  catarrh,  dyspepsia,  and  sick  head- 
aches. An  attack  of  the  latter  culminated  in  a  violent 
and  prolonged  convulsion,  followed  by  stupor  and 
headache,  lasting  for  six  hours.  An  examination  of 
the  urine  showed  it  to  be  highly  albuminous,  and  that 
nephritis  was  fully  developed.  The  patient  was  treated 
for  some  time  with  helonias,  corrosive  sublimate,  arsenic, 
aurum,  the  phosphate  of  strychnia,  and  iron,  without 
any  radical  improvement,  the  urine  never  being  free 
from  albumin,  and  the  headache  being  in  a  more  or 
less  degree  constant.  The  patient  became  emaciated 
and  ansemic. 

Recent  experiments  with  calomel,  podophyllum,  and 
euonymine  having  shown  the  latter  to  be  the  most 
valuable  cholagogue  of  any  of  these,  and  considering  in 
this  particular  case  that  a  disordered  condition  of  the 
liver  had  much  to  do  with  the  nephritis,  he  determined 
to  direct  the  treatment  to  the  relief  of  the  deranged 
hepatic  functions,  and  prescribed  euonymine  three  times 
daily.  At  the  end  of  a  week  the  albuminous  urine  and 
headaches  had  entirely  disappeared  ;  same  treatment 
continued.  The  euonymine  was  then  suspended,  when 
at  the  end  of  a  week  the  albumin,  nausea,  and  head- 
ache had  all  returned.  Euonymine  being  resumed,  the 
urine  became  normal  in  a  few  days,  and  has  remained 
so.  This  remedy  was  continued  for  several  months,  and 
effected  a  complete  cure. 

In  another  patient,  an  adult  male,  who  had  suffered 
for  more   than  a  year  from   dyspepsia,  depression  of 


ACUTE   NEPHRITI^^ — TREATMENT.  195 

spirits,  and  pains  in  tlie  back  and  head,  the  urine  was 
found  to  be  highly  albuminous.  iSTo  remedies  which 
were  administered,  except  strychnine,  caused  the  al- 
bumin to  disapjDear  even  for  a  short  time.  Euonymine 
in  two  weeks  brought  about  a  complete  disappearance 
of  albumin,  and  in  two  months  the  patient's  health 
was  fully  restored. 

Of  course  it  would  add  to  the  importance  of  these 
cases  had  the  results  of  microscopic  examinations,  if 
made,  been  given  ;  but  they  are  interesting  in  showing 
that  the  plant  has  valuable  properties  in  certain  condi- 
tions of  nephritis.  The  great  benefit  derived  from  the 
administration  of  this  remedy  in  these  two  cases  (I  have 
not  known  of  its  use  in  others)  shows  it  to  be  worthy  of 
further  investigation  and  trial.  The  recovery  of  the 
first  case  of  albuminuria — if  dependent,  as  it  often  is, 
npon  hepatic  derangement — was  probably  effected  by 
the  restoration  of  the  integrity  of  the  functions  of  the 
liver ;  it  is  possible  that  the  euonymine  may  have  re- 
lieved the  nephritis  by  virtue  of  its  tonic,  astringent,  or 
diuretic  properties,  or  all  combined.  Euonymus  atro- 
purpureus  has  long  been  used,  but  mostly,  I  believe, 
by  the  eclectics.  It  is  known  to  be  a  valuable  chola- 
gogue  and  cathartic,  operating  without  griping.  It  is 
also  an  antiperiodic  and  diuretic.  The  fluid  extract 
from  the  bark  is  a  reliable  preparation. 

I  should  regard  the  muriate  of  ammonia  as  perhaps 
the  most  valuable  remedy  in  general  stasis  of  the  cii'cu- 
lation  of  the  liver,  not  dependent  on  structural  changes, 
and,  so  far  as  the  derangement  of  the  kidneys  depended 
upon  deranged  hepatic  functions,  calculated  to  be  of 
great  use.  Its  value  in  torpid  conditions  of  the  liver, 
jaundice,  etc.,  has  been  too  often  shown  to  require  from 
me  any  disquisition  relative  thereto. 

I  have  mentioned  no  remedies  which  have  not  been 
proved  to  be  efficacious  or  curative.     There  are  many 


196  bkight's  disease. 

remedies,  however,  that  are  recommended  on  theoretical 
grounds.  According  to  the  law  of  cure  claimed  by  the 
homoeopathic  school,  iDliosjiliorus  should  be,  particu- 
larly in  croupous  nephritis,  a  valuable  remedy,  since 
we  find  that  it  causes  hypertrophy,  followed  by  con- 
traction of  the  liver,  jaundice,  diabetes,  scanty  albumi- 
nous urine,  fatty  degeneration  of  the  liver  and  kidneys. 
The  epithelia  of  the  latter  become  swollen,  granular, 
fatty,  and  finally  are  destroj^ed.  This  drug  also  pro- 
duces bloody  urine,  epithelial  or  granular  casts,  and 
sometimes  a  copious  flow  of  watery,  colorless  urine. 
This  school  claims  that  this  remedy  and  arsenic  should 
be  potent  in  the  treatment  of  nephritis,  but  I  have  not 
been  able  to  find  any  records  of  cases  treated  with 
benefit  by  the  former. 

Opium,  in  ursemic  convulsions,  is  often  employed,  and 
sometimes  with  advantage.  Prof.  A.  L.  Loomis  rec- 
ommends hypodermic  injections  of  half  a  grain  or  more 
of  morphia,  and  Prof.  J.  H.  Eipley  also  states  that 
his  own  experience  of  the  hypodermic  use  of  morphia  in 
convulsions  has  been  favorable.  I  have,  in  one  instance, 
known  this  to  be  used  with  apparent  success.  Opium, 
however,  limits  the  renal  secretion  especially,  and  its 
administration  in  small  doses  often  develop  comatose 
symptoms.  I  am  opposed  to  its  use  despite  the  benefit 
which  it  sometimes  seems  to  confer. 

The  hydrate  of  chloral  can  be  resorted  to  with,  I  be- 
lieve, equal  benefit  in  ursemic  convulsions.  Tyson' 
highly  recommends  its  use,  and  I  myself  have  with  great 
benefit  used  rectal  injections  of  it ;  the  dose  for  a  child 
being  10  to  30  grains. 

Bleeding  from  the  arm,  in  convulsions,  is  recom- 
mended by  the  same  author,  who  quotes  Dr.  Hiram  Cor- 
son as  having  found  it  beneficial.     Tyson  says:   "No 


'  Bright's  Disease. 


ACUTE   NEPHRITIS— TREATMENT.  197 

one  doubts  tlie  efficacy  of  bleeding  in  puerperal  convul- 
sions, and  if  puerperal  convulsions  are  urseniic,  as  I  be- 
lieve tliey  mainly  are,  then  bleeding  should  be  of  use 
in  ursemic  convulsions  of  acute  Bright' s  disease."  I 
have  not  employed  phlebotomy,  but,  under  proper  cir- 
cumstance, should  do  so. 

The  following  cases  illustrate  the  efficacy  or  action  of 
some  of  the  remedies  and  methods  of  treatment  I  have 
described  in  this  chapter  : 

Case  III. — Acute  Groupoiis  Ne])hrUis  loith  Hydrothm^ax. — December 
4,  1880,  I  saw,  in  consultation  with  her  j)hysician,  a  girl  nine  years 
of  age  suffering  from  dropsy,  the  result  of  scarlatina  anginosa.  Twenty- 
one  days  had  elapsed  from  the  commencement  of  the  disease. 

I  found  oedema  pulmonum  and  extensive  hydrothorax  ;  the  face  and 
eyelids  wei'e  much  swollen,  the  latter  so  as  almost  to  close  the  eyes. 
Severe  orthoj)noea,  and  impossibility  of  lying  down ;  pulse  small ;  ex- 
tremities cold ;  lips  blue ;  urine  highly  albuminous,  very  scanty, 
dark  and  smoky,  specific  gravity  1018 ;  numerous  blood  corpuscles 
and  granular  and  epithelial  casts.  Prescribed  calomel,  one-tenth 
grain  every  three  hours,  and  5  drops  of  a  ten  per  cent,  mixture  of 
pure  nitric  acid  three  times  daily. 

December  5th. — Passed  8  oz.  urine ;  respiration  easier.  6th. — 
Passed  22  oz.  urine ;  oedema  of  lungs  and  face  much  better.  As  the 
mercury  commenced  to  have  a  laxative  effect,  I  ordered  it  given  every 
two  hours.  7th. — Less  albumin ;  24  oz.  urine  of  a  light  color ;  still 
improving;  hydrothorax  better,  face  natural.  8th. — Hydrothorax  al- 
most gone ;  can  lie  down  with  ease ;  the  mercury  to  be  given  every 
three  hours ;  nitric  acid  continued.  The  urine  was  now  secreted  in 
abundance,  and  was  of  low  specific  gravity ;  quantity  moderate. 

The  recovery  was  eventually  complete ;  after  the  subsidence  of  the 
acute  and  dangeroiis  conditions  other  remedies  were  employed,  among 
them  cantharides  and  iron.  It  was,  however,  more  than  two  months 
from  the  time  I  commenced  the  treatment  before  the  albumin  had 
completely  disappeared. 

Case  IV. — Acute  Hemorrhagic  Croupous  Nephritis  from  Cold. — ^J. 
L ,  aged  twenty  mouths,  who  had  been  suffering  from  difficult  den- 
tition, diarrhoea,  and  a  severe  cold  affecting  the  nasal  mucous  mem- 
brane, throat,  and  chest,  suddenly  (January  2d)  became  oedematous 
about  the  face  and  feet. 


198  bright' S   DISEASE. 

There  had  been  for  several  days  great  languor  and  debility.  Urine 
was  found  to  be  highly  albuminous,  specific  gravity  1024,  very  scanty, 
and  containing  blood  coiijuscles,  blood  and  epithelial  casts.  Gave  the 
2d  trit.  of  corrosive  sublimate,  about  10  gi'ains  every  hour,  and  ^^  of  a 
drop  of  pure  nitric  acid  well  diluted,  three  times  a  day.  January  3d. 
— Not  much  change.  4th. — More  urine,  less  albumin.  5th. — Urine 
much  increased,  lighter  color.  6th. — Still  improving,  passes  water  now 
in  normal  quantities,  no  blood,  specific  gravity  1015.  Prescribed  the 
bichloride  and  cantharides,  each  in  10-grain  doses,  the  2d  trit. ,  that  is, 
1  part  of  the  drug  to  about  10,000  sugar  and  milk,  in  alternation,  an 
hour  and  a  half  to  two  houi's  apart.  9th. — Urine  perfectly  normal  and 
so  remained.  As  a  precaution  I  continued  the  remedies,  however,  for 
several  days.  The  skin  during  the  attack  was  dry  and  unperspira- 
ble,  and  had  not  the  remedies  brought  about  an  improvement  I  should 
have  used  the  hot-air  bath,  though  with  hesitation,  as  there  was  con- 
siderable initation  from  teething. 

CaseV. — Acute  Croupous  Nephritis  in  an  Adult,  from  Fever  and  Ague. 

— October  31,  1877,  I  was  called  to  attend  C.  F ,  aged  thii-ty-one, 

who  had  had  during  the  preceding  summer  severe  fever  and  ague. 
He  had  been  only  j)artially  cured,  and  for  two  weeks  before  I  saw  him 
had  suffered  from  chilliness,  aching  in  bones,  debility,  headache, 
heavily  coated  tongue,  loss  of  appetite,  and  constipation.  The  char- 
acteristic symptoms  of  bilious  remittent  fever  at  last  became  mani- 
fest ;  morning  temperature,  100° ;  evening,  104° ;  severe  nausea  and 
vomiting ;  urine  not  albuminous,  but  scanty  and  high-colored.  At 
the  end  of  ten  days  the  fever  was  gone,  but  an  inexplicable  condition 
of  inertia  and  exhaustion  remained,  with  heavily  coated  tongue  and 
complete  anorexia. 

November  12th  he  complained  of  violent  nausea,  and  there  was  some 
oedema  of  the  eyelids ;  considerable  pain  over  the  kidneys ;  urine 
scanty  and  smoky,  and  highly  albuminous,  with  some  epithelial  casts ; 
only  8  oz.  jjassed  in  the  preceding  twenty-four  hours.  As  the  hepatic 
functions  had  all  the  while  been  deranged,  I  gave  10  grains  of  calo- 
mel, followed  the  next  morning  by  three  teaspoonfuls  of  the  natural 
Carlsbad  (Sprudel)  salts.  Free  catharsis  was  produced.  I  also  pre- 
scribed 10  grains  of  a  one  ^ev  cent,  trituration  of  calomel  to  be  given 
hourly,  and  ordered  the  hot-air  bath  to  be  used  daily.  13th. — 6  oz. 
urine ;  specific  gravity  1024 ;  some  blood  coi-puscles.  As  the  bath 
produced  abundant  sweating  he  felt  no  worse.  Face  much  bloated. 
Podophyllum,  ext.  fl. ,  to  be  given  alternately  with  the  hydrarg. 
chlorid.  mite  an  hour  apart.  14th. — All  symptoms  better  ;  6  oz.  lu'ine 
(there  had  been  very  profuse  sweating),  less  albumin.     15th. — As  the 


ACUTE   NEPHEITIS — TREATMENT.  199 

calomel  was  prodticing  a  laxative  effect,  I  substituted  the  corrosive 
sublimate  ;  16  oz.  urine,  no  blood  cori:)Uscles,  less  albumin ;  hot-air 
bath  every  other  night.  18th. — 14  oz.  urine ;  nausea,  headache,  and 
oedema  of  the  face  gone.  20th.— Improving;  hot-air  bath  every 
fourth  night;  urine  abundant  on  the  days  the  hot-air  bath  was  not 
used.  The  mercury  and  nitric  acid  were  given  without  intermission 
until  December  12th,  when,  as  there  had  been  for  three  days  an  en- 
tire absence  of  albumin,  I  prescribed  -h  grain  of  arsenic  three  times 
daily,  and  the  Carlsbad  water  in  cathartic  doses  every  morning.  Iron 
and  quinine  were  afterward  given.  The  patient  has  enjoyed,  in  nearly 
every  respect,  perfect  health  up  to  this  time. 

Case  VI. — Acute  Croupous  Nephritis,  after  Scarlatina  and  Diphthe- 
ria. —Louise  C ,  aged  seven,  on  March  15,  1876,  was  seized  with 

malignant  scarlatina.  All  the  symptoms  were  severe,  and,  to  add.  to 
the  gravity  of  the  case,  in  a  few  days  an  abundant  diphtheritic  exuda- 
tion formed  in  the  throat  and  nasal  canals ;  there  was  at  one  time 
complete  coma  lasting  twenty-four  hours,  and  there  seemed  to  be,  for 
several  days,  no  chance  of  recovery.  The  scarlatina  and  diphtheria, 
however,  in  time  improved,  biat  the  joints  became  swollen,  large  ab- 
scesses formed  in  the  neck,  there  was  ulceration  of  both  ears,  and  the 
renal  functions  became  impaired,  April  7th  the  urine  becoming  scanty 
and  loaded  with  albumin ;  oedema  pulmonum  and  hydrothorax  to  a 
moderate  extent  soon  supervened,  and  oedema  of  face  and  lids ;  the 
urine  was,  however,  secreted  in  siifficient  quantities  to  relieve  the  sys- 
tem somewhat  (6  oz.  in  twenty -four  hours). 

I  gave  calomel,  the  1st  trituration  (that  is,  1  part  to  99  of  sugar 
of  milk),  10  grains  every  two  hours,  and  5  drops  of  a  ten  per  cent, 
dilution  of  nitric  acid,  three  times  daily,  and  in  five  days  the  oedema 
had  gone,  and  8  oz.  of  urine  were  voided.  The  hot-air  bath  was  em- 
ployed daily.  I  administered  calomel  in  this  case,  because  I  have 
found  it  of  especial  value  in  albuminuria  where  there  were  serous  effu- 
sions. These  two  remedies  brought  about  an  entire  subsidence  of  the 
renal  symptoms,  except  of  the  albumin,  which  persisted  in  consider- 
able quantities  for  a  long  time. 

I  find,  for  instance,  that  from  the  26th  of  April  to  the  26th  of  May 
(the  forty-first  to  the  seventieth  day  of  the  disease)  the  average  spe- ' 
cific  gravity  was  about  1011,  being  secreted  in  suflflcient  quantities ; 
there  were  a  very  few  granular  and  hyaline  casts.  No  remedies  which 
I  administered,  beyond  a  certain  point,  produced  any  effect  in  dimin- 
ishing the  albumin ;  corrosive  sublimate,  arsenic,  and  apis  were  all 
used.  Regarding  the  pathological  condition  to  be  one  of  debility  of 
the  renal  circulation,  I  administered  chloride  of  iron  and  cantharides, 


200  bright' S   DISEASE. 

with  the  effect  of  arresting  the  secretion  of  albumin  in  six  or  seven 
clays. 

Case  VII. — Acute   Croupous  Nephritis  after  Scarlatina. — D.  F , 

aged  twelve.  Had  a  severe  attack  of  scarlatina  anginosa,  followed  by 
oedema  of  face  and  limbs,  nausea,  and  scanty  urine,  which  was  highly 
albuminous,  and  was  found  to  contain  blood  corpuscles  and  epithelial 
and  blood  casts.  The  administration  of  corrosive  sublimate,  2d  tritu- 
ration (that  is,  about  1  jiart  to  10,000),  in  10- grain  doses  an  hour  or  two 
apart,  rapidly  brought  about  a  normal  condition  of  the  urine  and 
kidneys. 

Case  VIII.' — Acute  Croupous  Nephritis,  with  Anuria  for  thirty -four 

hours,  following  Diphtheria. — Kate  M ,  aged  ten,  was  taken  with 

severe  diphtheria,  the  case  being  the  worst  I  have  yet  known  to  recover. 
The  details  are  unnecessary,  but,  at  the  end  of  twenty-four  days,  the 
membrane  had  wholly  disappeared  from  the  air-passages,  throat,  and 
nose.  About  this  time  I  detected  albumin,  for  which  I  had  been  anx- 
iously on  the  watch,  in  the  urine.  It  first  made  its  appearance  in 
small  quantities,  but  soon  became  abundant.  This  was  soon  followed 
by  severe  naiisea,  the  result  of  ursemic  poisoning  and  partial  anuria. 
Some  blood  corpuscles  and  hyaline  and  epithelial  casts  were  found  in 
the  urine,  which  was  of  high  specific  gravity.  In  order  to  relieve  the 
kidneys  as  much  as  possible  from  their  work  of  excretion,  I  resorted 
to  Eonchetti's  hot-air  bath,  which  produced  profuse  sweating.  This 
was  used  two  nights  in  succession.  Internally  I  administered  the  2d 
trit.  of  corrosive  sublimate,  in  alternation  with  cantharides,  half  an 
hour  apart. 

In  about  a  week  the  albumin  had  wholly  disappeared,  and  the  urine 
had  become  quite  normal. 

Convalescence  now  proceeded  rapidly.  November  26th  she  was  re- 
moved to  another  room,  which  from  the  arrangement  of  the  doors  and 
windows,  admitted  draughts.  The  next  day  I  found  my  patient  very 
restless  and  with  occasional  labored  breathing ;  the  pulse  was  irreg- 
ular and  somewhat  tense ;  the  heart  was  intermittent,  its  action 
labored,  and  occasionally  there  was  &  pulsus  dicrotus,  and  the  next  day 
the  secretion  of  urine  became  suddenly  arrested.  I  attributed  these 
untoward  events  to  "catching  cold,"  as  the  weather  had  suddenly  be- 
come very  cold. 

Nausea  once  more  set  in,  with  violent  retching,  and  at  1  a.m.  No- 
vember 29th,  I  was  informed  that  the  child  was  very  low.     On  amv- 

'  From  a  paper  on  Diphtheria,  read  before  the  New  York  Medico-Chirur- 
gical  Society,  February,  1879. 


ACUTE   NEPHRITIS — TREATMENT.  201 

ing,  I  found  my  patient  cold,  livid,  and  gasping  for  breath.  An  ex- 
amination of  the  heart  disclosed  the  existence  of  pericardial  effusion, 
the  area  of  dulness  was  increased,  the  valvular  sounds  muffled,  and 
the  pulse  feeble,  intermitting,  and  dicrotic. 

No  urine  had  been  passed  for  thirty-four  hours.  I  had,  upon  the  su- 
pei-vention  of  the  new  conditions  of  November  28th,  commenced  the 
administration  of  digitalis  gtt.  ij.,  and  calomel,  10  grains  of  the  1st  trit., 
half  an  hour  apart. 

I  now  proceeded  to  give  every  hour  a  mixture,  each  dose  of  which 
contained  spirits  nitric  ether,  gtt.  xv.;  wine  of  squills,  gtt.  xij.,  and 
tinct.  digitalis,  gtt.  iij|^'. 

The  wine  of  squills  I  hesitated  to  give,  as  its  effect  upon  the  kidney 
is  irritating,  and  acute  inflammation  existed,  but  thought  the  neces- 
sity of  obtaining  relief  from  the  dropsical  effusion  by  diuresis  to  pre- 
dominate over  this  objection.  The  condition  of  the  heart  precluded 
the  employment  of  the  hot  air  bath. 

To  relieve  the  sinking  energies  and  intense  prostration,  I  adminis- 
tered, from  time  to  time,  the  compound  spirits  of  ether,  brandy,  and 
ammonia.  The  effect  of  the  diuretic  mixture  was  beneficial,  as  in  two 
or  three  hours  the  child  passed  about  6  oz.  of  urine,  the  first  she 
had  voided  in  thirty-six  hours.  The  mixture  of  squills,  digitalis,  and 
nitric  ether  was  continued  in  alternation  with  calomel  the  remainder 
of  the  day.  At  8  p.m.  she  passed  about  4  oz.  more  of  urine.  The 
action  of  the  heai-t  remained  about  the  same,  though  there  was  less 
exhaustion.  This  last  condition  became  alarming  at  night,  however, 
and  so  critical  was  the  child's  condition  that  the  presence  of  a  physi- 
cian was  required  all  night.  The  next  morning  she  passed  again  about 
6  oz.  of  urine,  which,  like  that  of  the  day  previous,  was  highly  albu- 
minous, and  in  the  evening  4  oz.  more. 

The  action  of  the  heart  was  better,  but  still  veiy  bad  ;  the  water  in 
the  pericardial  sac  had,  however,  disappeared.  The  extremities  were 
cold,  but  the  dyspnoea  was  somewhat  better.  I  was  anxious,  in  some 
manner,  to  relieve  the  system  of  the  aqueous  elements  which  the  kid- 
neys were  unable  to  separate,  and  determined  to  try  the  effects  of 
jaiorandi,  hoping  to  obtain  copious  diaphoresis.  I  commenced  giv- 
ing 10-drop  doses  of  the  fluid  extract  in  alternation  with  calomel,  an 
hour  ajDart,  gradually  increasing  the  dose  to  from  15  to  20  drops,  until 
the  child  took  in  twenty-four  hours  nearly  half  an  ounce. 

'  IJ .  Spiritus  setheris  nitrici |  ij. 

Vini  scillie 5  iss. 

Tinct.  digitalis §  ss. 

M.  Dose,  30  drops. 


202  bright' S   DISEASE. 

I  did  not  administer  tliese  massive  doses  without  thoroughly  taking 
into  consideration  the  tendency  of  the  dnig  to  produce  prostration, 
and  I  watched  narrowly  for  any  manifestation  of  depression.  Not  only 
did  it  produce  no  poisonous  or  deisressing  symptoms,  but,  to  my  sur- 
prise, produced  not  the  slightest  diaphoretic  or  sialogogue  effect. 
The  inertness  of  the  dinig  in  this  case  is  to  me  still  unaccountable,  as 
I  believe  the  preparation  used  was  perfectly  reliable.  Keeping  in  mind 
these  two  cardinal  points,  to  relieve  the  nephritis  and  to  support  the 
muscular  power  of  the  heart,  I  determined  to  administer  corrosive 
sublimate,  10  grains  of  a  trituration  containing  1  pari;  in  10,000,  and 
tiuct.  digitalis  gtt.  ij.,  half  an  hour  aj)art.  My  course  was  rewarded  by 
an  increased  flow  of  urine,  in  which  I  found  for  the  first  time  an  excess 
of  urates  over  the  albumin,  which  was  still  abundant. 

Finally,  from  the  moment  of  the  profuse  deposit  of  urates  the  albu- 
min began  to  diminish,  and  in  a  short  time  had  quite  disappeared,  and 
there  was  an  abundant  secretion  of  urine. 

There  was  no  further  disturbance  of  the  kidneys,  but  December  5th, 
when  everything  as  regards  them  had  become  noiTual,  an  apoplectic 
stroke  occui-red,  producing  blindness  of  the  left  eye  and  entire  loss  of 
power  of  the  left  leg  and  arm. 

Case  IX. — Acute  Hemorrhagic  Croupous  Nephritis,  with  Urcemic  Con- 
vulsions.— "Was  called  by  her  physician,  in  February,  1882,  to  see  C. 
G ,  aged  fourteen.  She  had  had  scarlatina  anginosa  with  diph- 
theria, followed  by  nephritis  with  diminution  of  urine,  severe  convul- 
sions, and  finally  comj^lete  anuria.  During  the  last  convulsion,  and 
the  day  before  I  saw  her,  the  physician  had  used  a  hypodermic  injec- 
tion of  i  gr.  of  moii^hine,  which  seemed  to  shorten  its  duration.  I 
advised  the  hot-air  bath  daily,  a  milk  diet,  and  10  grains  of  the  2d 
trituration  of  bichloride  =  -nhro  graiH)  alternately  with  similar  doses 
of  cantharides,  half  an  hour  apaii. 

In  twelve  hours  there  was  some  uiine  passed.  The  urine  last  passed 
I  found  to  be  highly  albuminous,  and  to  contain  blood  coi-puscles  in 
large  number,  leucocytes,  numerous  blood,  epithelial,  and  granular 
casts,  and  pus  coi-puscles.  At  the  end  of  twelve  hours,  in  addition  to 
the  two  above  remedies,  the  diuretic  mixture  of  squills,  digitalis,  and 
spirits  of  nitric  ether  was  given  three  times  daily.  These  were  the 
essential  features  of  treatment,  which  were  followed  by  an  increased 
flow  of  urine  and  a  diminution  of  abnormal  elements  in  it.  There 
were  no  more  con^ailsions.  Secale,  iron,  arsenic,  and  quinine  were 
aftei'ward  given  with  benefit.  It  was  more  than  two  months  before 
the  albumin,  epithelia  from  the  tubules,  pus,  etc.,  had  entirely  disap- 
peared. 


CHAPTER  XXII. 

TREATMENT   OF   CHRONIC   NEPHRITIS. 

It  seems  unnecessary,  as  it  is  almost  impossible,  to 
make  the  treatment  of  each  form  of  nephritis  the  sub- 
ject of  individual  consideration,  on  the  theory  that 
there  is  any  great  difference  in  the  character  of  the  rem- 
edies in  use  or  in  their  mode  of  employment.  The 
chapter  on  the  treatment  of  acute  nephritis  compre- 
hends that  of  acute  interstitial  and  acute  croupous 
nephritis,  tliough  the  former  we  seldom  have  to  deal 
with.  The  same  principles  and  remedies  which  are  ap- 
plicable to  the  acute,  are  appropriate  to  the  chronic  form. 
Still,  in  the  latter  there  are  measures  and  remedies  not 
applicable  nor  of  use  in  acute  nephritis,  and  as  in  the 
chronic  forms  there  are  differences  in  the  treatment  re- 
quired, it  is  essential  that  different  chapters  should  be 
devoted  to  them. 

An  important  general  distinction  in  the  selection  of 
remedies  in  acute  and  chronic  nephritis,  is  that  whereas 
a  certain  class  of  irritant  and  stimulating  diuretics,  as 
squills,  iron,  cantharides,  turpentine,  etc.,  are  some- 
times not  only  useless  but  dangerous  in  acute  inflam- 
mation and  recent  congestion  of  the  kidneys,  in  propor- 
tion as  these  conditions  recede  from  an  acute  or  recent 
character,  they  will  be  found  appropriate  and  service- 
able. 

That  even  both  chronic  croupous  and  interstitial  ne- 
phritis are  sometimes  cured  (or  recover),  there  is  no 
doubt.     Naturally  the  grades  and  conditions  of  chronic 


204  bright' S   DISEASE. 

nephritis  are  numerous.  Wlien  the  epithelia  of  a  large 
portion  of  the  convoluted  tubules  are  fatty,  waxy,  des- 
quamated, and  their  places  supplied  by  endothelia  ;  the 
functions  of  the  tufts  irrevocably  destroyed  by  thicken- 
ing of  their  connective  tissue,  and  the  capsules  filled 
with  albuminous  and  indifferent  material  ;  when  the 
blood-vessels  have  undergone  extensive  waxy  changes, 
or  many  of  them  have  become  obliterated  ;  and  the 
tubules  are  destroyed  and  replaced  by  thickened  con- 
nective tissue,  or  the  whole  kidney  is  shrunk  or  per- 
manentl}"  enlarged,  of  course  a  restoration  to  health  is 
not  to  be  sought. 

Still,  there  are  very  many  cases  of  croupous  and  in- 
terstitial nephritis  in  which,  although  the  rational 
symptoms,  as  dropsy,  headache,  epistaxis,  convulsions, 
etc.,  seem  to  indicate  extensive  and  permanent  organic 
changes  in  the  kidney,  we  may  have  no  evidence  that 
more  than  a  limited  portion  of  the  interstitial  and 
secreting  structures  is  affected  ;  or  the  changes  may  be 
of  such  recent  existence  as  to  justify  a  hope  and  an  at- 
tempt to  eradicate  them.  At  all  events,  unless  it  be 
clearly  evident  that  extensive  organic  changes  exist,  or 
unless  other  complications  and  constitutional  conditions 
militate  against  the  possibility  of  recovery,  a  cure  is 
always  to  be  hoped  for  and  essayed. 


CHAPTER  XXIII. 

TREATMENT   OF   CHRONIC   INTERSTITIAL  NEPHRITIS. 

Though  many  of  the  same  remedies  and  measures  of 
treatment  apply  equally  in  clironic  croupous  and 
chronic  interstitial  nephritis,  still  there  are  differences 
required,  often  of  an  essential  and  vital  character. 

As  I  have  said,  cases  of  chronic  interstitial  nephritis  are 
cured  or  recover,  but  in  attempting  to  accomplish  a  cure, 
the  practitioner  will  err  if  he  rely  solely  upon  the  wise 
and  appropriate  selection  of  drugs.  It  will  be  fortunate 
if  his  patient  be  so  situated  that  he  can  have  the  advan- 
tage of  rest,  mentally  and  bodily.  The  influence  of  the 
latter  has  been  shown  to  be  of  the  greatest  value  in 
diminishing  albuminous  exudation  from  the  kidneys. 
If  fatiguing  avocations,  physical  or  mental,  must  be 
pursued,  and  those,  too,  in  the  trying  and  variable  cli- 
mate of  the  temperate  zones,  comparatively  little  can  be 
accomplished. 

The  patient  must  not  only  be  able  to  remain  indoors 
if  necessary,  but  if  the  albuminous  exudations  do  not 
clear  up  with  the  appropriate  treatment,  much  benefit 
will  sometimes  be  derived  by  keeping  him  in  bed  for 
several  days  until  it  do,  if  it  can  be  made  to  disappear  ; 
and  the  same  measure  should  be  resorted  to  at  once, 
again,  upon  the  recurrence  of  albuminuria.  Fatiguing 
exercise  must  always  be  avoided,  and  even  moderate 
muscular  exercise  sometimes  does  harm. 

So  pregnant  a  cause  of  interstitial  nephritis  are  atmos- 
pheric influences  and  damp  cold — the  most  frequent, 


206  beight's  disease. 

indeed — tliat,  in  unfavorable  seasons  of  the  year,  it 
might  be  important  for  the  patient  to  have  recourse  to  a 
Southern  climate.  In  our  own  country  we  have  in  South 
Carolina,  Georgia,  and  Florida  an  equable  climate,  with 
warm,  dry  air ;  while  to  those  who  are  benefited  more 
especially  by  sea  air,  IN'assau  and  Bermuda  are  accept- 
able. A  dry  and  even  climate  is  always  to  be  desired. 
On  the  Continent,  the  Mediterranean  coast  has  many 
advantages.  Mentone  is  mild  and  sedative  ;  Nice  less 
so  ;  Cannes  and  Hyeres  are  less  variable  and  warmer 
than  Nice.  There  are  many  towns  along  the  Riviera 
which  are  more  or  less  good  ;  as  San  Remo,  Monte 
Carlo,  Bordighera,  etc.  In  France,  Biarritz,  on  the 
Bay  of  Biscay,  has  many  advantages  as  a  winter  re- 
sort, such  as  good  hotels,  pleasant  drives  and  surround- 
ings, and  a  warm,  sunny  exposure.  Arcachon,  situated 
on  a  large  basin  or  lake  communicating  with  the  Bay 
of  Biscay,  about  an  hour's  distance  from  Bordeaux,  is 
a  favorite  winter  resort ;  its  climate  is  very  much  like 
that  of  Biarritz,  but  it  is  more  sheltered.  It  is  on  a  vast 
sandy  plain,  of  which  a  great  part  is  thickly  wooded 
with  pine.'  The  accommodations  as  a  winter  resort  are 
excellent.  Pau  is  not  desirable,  though  the  temperature 
and  equability  recommend  it,  as  there  is  too  much  rain. 
Amelie-les-Bains,  the  most  eastern  of  the  Pyrenean,  and 
indeed  of  the  French  winter  resorts,  situated  near  Per- 
pignan  and  the  Gulf  of  Lj^ons,  enjoys  an  equable,  mild 
temperature,  and  there  is  but  little  rain,  and,  as  in  Pau, 
when  it  occurs  there  is  but  very  little  sense  of  humidity. 
It  is  very  well  protected  from  the  north  by  the  chain  of 
the  Canigou.  The  climate  is  sedative.  Egypt  possesses, 
perhaps,  the  greatest  advantages ;  the  absence  of  hu- 
midity in  the  winter,  the  equal,  warm  temperature,  and 
the  invigorating  qualities  of  the  air,  make  it  a  most 

^  Arcachon,  in  patois,  signifies  resin. 


CHEONIC   INTERSTITIAL   NEPHRITIS — TREATMENT.      207 

desirable  winter  resort.  Algiers  may  also  be  recom- 
mended on  the  same  grounds,  though  less  desirable 
than  Upper  Egypt.  Rome  and  Naples  possess  very 
great  advantages  as  winter  resorts,  in  chronic  nephritis, 
as  regards  warmth  and  equability  of  temperature  and 
comforts  of  living.  Madeira  and  Malaga  are  excellent 
as  winter  climates,  but  the  latter  is  lacking  greatly  in 
comforts,  cleanliness,  and  modern  hygienic  appliances. 
Some  constitutions  will  be  most  benefited  by  intense 
heat,  and  will  find  tropical  climates  advantageous.  Per 
contra^  patients  who  are  comfortably  situated  at  home 
should  not  be  sent  away  unless  the  accessories  of  good 
rooms,  nursing,  food,  etc.,  can  be  had.  I  am  familiar 
with  many  places  of  health  resort  upon  the  Continent, 
and  I  have  never  seen  medical  astuteness  more  at  fault 
than  in  sending  patients  in  advanced  stages  of  various 
diseases  to  climates  and  springs  indifferently  suited  to 
their  cases — living  in  cramped  apartments,  and  with  in- 
different nursing  and  care.  Often  the  patient  wanders 
about  from  one  station  to  another  in  the  vain  hope  of 
finding  relief,  becoming  an  object  of  commiseration  to 
others  and  obtaining  more  injury  than  benefit. 

Silk,  or  all  wool  undergarments,  of  various  thick- 
nesses, according  to  the  seasons,  should  be  worn  next 
the  skin  the  entire  year. 

Dietetic  Measures. — These  are  of  great  importance. 
Many  physicians  limit  the  amount,  and  almost  prohibit 
the  use,  of  highly  nitrogenized  food,  on  the  theory,  I 
suppose,  that  more  uric  acid  must  not  be  allowed  to 
form  than  can  be  eliminated  ;  the  danger  of  ursemic 
poisoning  being  thereby  increased.  It  is  well  known 
that  in  interstitial  nephritis  the  amount  of  uric  acid  ex- 
creted is  diminished,  that  of  urea  often  remaining  nor- 
mal. Undoubtedly,  the  danger  of  ursemic  poisoning 
would  be  increased  by  imposing  upon  the  system  more 
nitrogenous  food  than  could  be  thoroughly  assimilated. 


208  bkight's  disease. 

leading  to  the  formation  of  more  uric  acid  than  the 
kidneys  could  excrete.  Still,  it  is  of  great  importance 
that  the  waste  of  albumin  going  on  nearly  all  the  time 
— the  loss  of  dried  albumin  in  twenty -four  hours  amount- 
ing sometimes  (in  croupous  nephritis),  according  to  Dr. 
Hasall,  to  310  grains,  equal  to  10  oz.  of  blood — should 
be  compensated  for,  and  that  such  food  should  be  taken 
as  would  supply  the  albuminous  waste  and  at  the  same 
time  not  overload  the  system  with  the  products  of  im- 
perfect assimilation.  It  must,  however,  be  remembered 
that  in  interstitial  nephritis  the  loss  of  albumin  is  usu- 
ally small,  never  so  great  as  in  croupous  nephritis,  and 
less  albuminous  food  seems  to  be  required.  Certainly, 
in  chronic  interstitial  nephritis  the  tendency  to  ursemic 
accidents  is  perceptibly  increased  by  a  free  indulgence 
in  animal  food.  I  have  found,  in  the  case  particularly 
of  a  gentleman  of  apoplectic  habit,  who  had  been  a  free 
liver,  and  had  suffered  intensely  with  ursemic  headaches, 
and  who  afterward  died  from  apoplexy,  that  a  purely 
Tnilk  diet  was  followed  by  a  better  state  of  the  system 
than  any  I  had  before  adopted ;  the  effect  as  regards 
the  albuminous  exudation  was  also  favorable. 

When  I  employ  this  diet  in  adults  I  allow  but  little 
of  other  food,  and  that  mostly  farinaceous,  but  have  the 
patient  take  several  quarts  of  milk  daily.  It  is  remarka- 
ble how  well  the  strength  of  an  adult  can  sometimes  be 
maintained  by  this  diet.  Koumyss  I  have  found  a  good 
article  of  food,  and  it  is  generally  agreeable ;  it  has  some- 
times the  effect  of  allaying  nausea.  Unfortunately,  how- 
ever, the  appetite  is  usually  so  indifferent,  if  not  absent, 
and  nausea  sometimes  so  troublesome,  that  the  patient 
cannot  take  sufficient  food. 

The  amount  of  animal  food  must  depend  upon  its 
effect  upon  the  patient's  system  and  upon  his  condition. 
I  have  found  cases  where  there  were  no  ursemic  symp- 
toms nor  headaches,  and  where  the  assimilative  powers 


CHRONIC   INTERSTITIAL   NEPHRITIS — TREAT3IENT.      209 

seemed  unimpaired,  benefited  by  a  liberal  diet  of  beef, 
mutton,  etc.,  while  others  could  take  no  nitrogenized 
food  stronger  than  chicken,  game,  veal,  oysters,  eggs, 
fish,  etc.  This  latter  can  be  eaten  freely.  Fruit,  vege- 
tables, etc.,  so  far  as  the  kidneys  are  concerned,  are 
unobjectionable.  Skimmed  milk  is  nourishing  and  re- 
freshing, easily  assimilable,  and  does  much  to  supply 
the  loss  of  albumin. 

Certain  alcoholic  beverages  are  sometimes  well  borne, 
and  do  much  toward  stimulating  the  depressed  energies 
and  limiting  the  waste  of  tissues.  Only  certain  kinds, 
however,  should  be  taken  ;  malt  liquors  are  injurious  ; 
spirits,  as  brandy  and  whiskey,  are  not  usually  well 
suited  to  nephritic  inflammation.  The  best  alcoholic 
beverages  are  those  containing  a  moderate  percentage  of 
alcohol,  say  five  to  eight  per  cent.,  as  light  Rhine 
wines  and  light  claret ;  the  astringent  properties  of  the 
latter  are  advantageous.  St.  Estephe,  when  the  genuine 
wine  can  be  obtained,  is  considered  in  anaemic  condi- 
tions one  of  the  most  tonic  of  the  Bordeaux  wines  ;  it 
contains  about  ten  per  cent,  of  alcohol.  Some  of  the 
Hungarian  wines,  notably  Carlowitz,  are  also  of  great 
value  where  there  is  much  anaemia.  Burgundies  are 
too  stimulating.  A  glass  of  very  dry  champagne  occa- 
sionally may  be  found  to  improve  the  appetite  and 
diminish  nausea. 

The  hot-air  or  vapor  bath,  or  the  wet  sheet,  as  de- 
scribed on  page  164,  should  be  employed  frequently ; 
where  it  is  accessible  the  Russian  vapor  bath  may  be 
resorted  to.  Neither  the  hot-air,  Russian  vapor,  nor 
Turkish,  bath  should,  however,  be  employed,  unless 
with  great  caution,  when  there  is  great  prostration,  or 
the  action  of  the  heart  is  very  feeble,  or  in  case  of  fatty 
degeneration,  or  other  serious  organic  trouble  or  severe 
functional  disorder  of  the  heart.  In  advanced  cases  of 
nephritis  these  baths  are  less  useful.     Jaborandi  or  pilo- 

14 


210  beight's  disease. 

carpin,  where  diaphoresis  is  necessary  and  the  use  of 
the  baths  is  not  expedient,  may  be  given. 

As  regards  the  curaMlity  of  chronic  interstitial 
nephritis^  and  as  to  what  may  he  accomplished  by 
treatment,  I  maintain  that  it  may  often  be  cured,  if 
early  recognized  and  properly  treated,  if  the  patient's 
constitution  be  good  and  the  organic  changes  be  not 
too  extensive  and  advanced.  Of  this  I  have  in  my  own 
practice  positive  proofs.  Much  sometimes,  of  course, 
dej)ends  upon  the  causology.  The  nephritis  caused  by 
and  accompanying  cystitis,  even  if  of  a  severe  character, 
almost  always  subsides  with  the  cystitis.  The  micro- 
scope will  show  all  the  evidence  of  organic  changes  in 
the  kidney,  as  casts,  epithelia  from  the  pelvis  and  the 
ticbuli  contorti,  but  with  the  cure  of  the  cystitis  all  the 
phenomena  of  nephritic  inflammation  will  entirely  dis- 
appear ;  permanently,  so  far  as  the  word  can  be  applied 
to  recovery  from  disease,  a  fact  which  certainly  shows 
that  chronic  nephritis  may  recover.  And  if  after  cysti- 
tis, why  not  after  other  causes  1 

But  excluding  the  matter  of  curability,  a  proper  un- 
derstanding of  this  form  of  nephritis  may,  under  favora- 
ble circumstances  and  in  many  forms  of  it,  prolong  life 
almost  indefinitely.  I  have  cases  of  it  under  my  care 
now,  some  of  which  have  existed  for  several  years,  with 
occasional  albuminuria,  and  where  a  fair  degree  of 
health  is  enjoyed ;  and  other  cases  without  albuminuria, 
where  as  yet  the  health  is  but  little  impaired.  There 
are  cases,  however,  which,  even  when  recognized  in  their 
very  inception,  are  destined  to  run  their  fell  course, 
rapidly  and  unsubdued,  and  almost  unalleviated  by  the 
resources  of  medicine,  even  when  it  is  in  the  power  of 
the  patient  to  resort  to  every  suitable  measure. 

Case  X. — For  example,  E.  E ,  aged  tliirty-nine,  who  liad  been  a 

long  time  under  my  care.  His  constitution  was  poor ;  there  was  con- 
sumption in  the  family ;   he  himself  possessed  a  very  robust  frame, 


CHRONIC    INTERSTITIAL   NEPHRITIS — TREATMENT.       211 

but  liad  always  been  a  liigli  liver.  He  liad  been  engaged  for  several 
years  in  arduous  and  successful  business,  and  had  become  much  ex- 
hausted, and  suffered  from  sleeplessness.  In  the  sj)ring  of  1881  he 
took  a  run  across  the  Atlantic,  the  entire  trijj  extending  over  a  period 
of  about  five  weeks.  The  weather  had  been  cold  and  inclement  on  sea 
and  on  land,  and  he  contracted  at  the  commencement  of  the  voyage  a 
severe  cold,  producing  more  or  less  chilliness,  fever,  aching,  etc.,  the 
eflPects  of  which  lasted  dui'ing  his  entire  absence.  I  saw  him  on  the 
day  of  his  return,  the  last  of  May,  and  found  him  suffering  from  nausea, 
weakness,  and  loss  of  appetite.  On  examining  the  urine,  I  recognized 
the  existence  of  mild  interstitial  nephritis  with  albuminuria.  Previous 
to  his  departure  I  am  sure  the  kidneys  were  healthy,  as  I  was  inclined 
to  refer  many  of  his  symptoms  to  some  derangement  of  those  organs, 
and  made  several  microscopic  examinations  of  the  urine.  I  ordered 
him  at  once  to  bed,  where  he  was  kept  nearly  a  month,  the  hot-air  bath 
was  used,  and  a  diet  of  milk,  broths,  fruit,  etc.,  adopted. 

TJie  case  seemed  so  mild  that  I  was  hopeful  of  favora- 
ble results ;  but  the  treatment  made  but  little  impres- 
sion upon  his  condition ;  violent  ursemic  headaches, 
great  debility,  nosebleed,  etc.,  manifested  themselves 
after  a  time,  and  he  died  in  a  comatose  condition,  in 
March,  1882.  An  autopsy  was  made,  which  confirmed 
my  diagnosis,  which  was  interstitial  nephritis  with  cir- 
rhosis. There  was  also  considerable  atheroma  of  the 
cerebral  arteries. 

I  suppose  this  nephritis  had  existed  about  a  month 
before  it  was  detected.  There  was  at  no  time  much  al- 
bumin, and  only  a  very  few  casts,  and  those  hyaline  ;  a 
few  pus  corpuscles  and  epithelia  from  the  convoluted 
tubules  were  always  to  be  found.  The  course  of  this 
disease  was  somewhat  rapid,  but  I  considered  its  refrac- 
tory, precipitate  character  in  a  great  degree  due  to  the 
unfortunate  constitution  of  the  patient. 

A  similar  case  (Case  XI.),  not  recognized  so  promptly 
as  the  preceding,  and  apparently  more  unpromising,  oc- 
curring in  a  young  lady  of  exceptionally  good  constitu- 
tion, which  will  be  given  further  on,  was  entirely  cured. 


212  bright' S   DISEASE. 

I  have  found  calomel  especially  suited  to  the  intersti- 
tial changes  which  occur  in  early  stages,  without  refer- 
ence to  other  conditions  and  complications. 

Some  reasons  for  its  suitability  I  have  already  en- 
deavored to  give,  together  with  the  manner  of  its  ad- 
ministration (see  pp.  187-8).  In  cirrhosis  perhaps  it  is 
useless,  except  in  preventing  new  growth  and  recur- 
rence. And  here  I  would  say,  that  to  cure  interstitial 
nephritis  it  must  be  recognized  before  cirrhosis  is  estab- 
lisJied.  I  usually  give  5  to  10  grains  every  three  or  four 
hours  of  the  1st  or  a  one  per  cent,  trituration,  or  per- 
haps of  a  preparation  of  1  part  to  1,000,  sometimes  giv- 
ing cantharides  in  the  same  doses  in  alternation  with  it, 
two  or  three  hours  apart.  Of  course,  if  the  nephritis 
have  existed  a  considerable  time,  with  albuminuria,  and 
there  are  evidences  of  considerable  affection  of  the  par- 
enchymatous and  interstitial  tissues,  with  hypertrophy 
of  the  heart,  perhaps  the  idea  of  a  cure  cannot  hardly 
be  entertained.  The  utility  of  this  remedy  in  one  in- 
stance out  of  a  number  is  shown  by 

Case  XI.  (referred  to  above). — L.  K ,  a  young  lady  sixteen  years 

of  age,  whose  own  constitution  was  not  only  excellent,  but  whose  parents 
and  grandparents  had  similar  constitutions,  was  placed  under  my  care 
December  17,  1877.  For  at  least  two  months  she  had  been  suffering 
from  extreme  lassitude,  intense  and  intractable  headaches,  nausea,  and 
nervousness  ;  complexion  sallow  and  turbid.  She  had  been  my  patient 
from  infancy,  and  as  she  had  been  subject  to  somewhat  similar  head- 
aches from  indigestion,  I  did  not  at  first  think  her  present  attacks 
came  from  the  kidneys,  and  made  no  examination  of  the  urine ;  the 
existence,  however,  of  some  oedema  of  the  eyelids  a  few  days  later,  led 
me  to  do  so.  I  found  it  albuminous,  and  to  contain  some  pus  corpus- 
cles and  epithelia  from  the  convoluted  and  straight  tubules.  There 
was  polyuria,  about  fifty  per  cent,  more  of  urine  being  passed  than 
usual ;  sjoecific  gravity  1012.  Action  of  the  heart  too  forcible,  and 
pulse  tense. 

She  was  kept  in  bed  and  the  hot-air  bath  was  employed  daily. 
Diet  farinaceous — fmit,  milk,  chicken-broth,  etc.  The  hydrarg.  chlo- 
ride mite,  ten  grains  of  a  one  per  cent,  trituration,  was  given  every 


CHRONIC   INTERSTITIAL   NEPHRITIS — TREATMENT.      213 

three  hours,  and  6  drops  of  a  ten  per  cent,  mixture  of  nitric  acid 
twice  a  day.  Under  the  influence  of  the  sweating  and  other  treatment 
the  amount  of  urine  diminished  and  became  less  albuminous.  Diet 
to  consist  of  animal  broths,  chicken,  fruits,  skim-milk,  eggs  ;  light 
claret  and  St.  Galmier  water  (one  of  the  best  natural  table  waters,  I 
think,  obtainable  here)  were  allowed.  At  the  end  of  a  week,  fearing 
some  constitutional  disturbance,  as  catharsis  or  the  specific  effects  of 
calomel,  I  substituted  for  it  the  hydrarg,  corrosiv.  chlorid.,  giving  10 
grains  of  a  trituration  of  1  part  to  500  of  sugar  of  milk,  and  ordered 
the  hot-air  baths  on  alternate  nights.  By  the  middle  of  February  the 
albumin,  headaches,  and  uraemic  symptoms  had  disappeared.  Allowed 
her  to  sit  up,  but  not  to  walk  about  the  room  much,  and  to  have  game 
and  oysters,  chicken  and  turkey ;  the  hot-air  bath  to  be  given  every 
five  days.  The  middle  of  March  she  was  apparently  well,  but  weak. 
In  February  there  were  occasionally  hyaline  casts,  pus  corpuscles,  and 
kidney  epithelia  ;  these  were  found,  though  in  diminished  numbers, 
upon  every  examination,  the  casts  finally  disappearing.  Her  health  did 
not  seem  in  every  way,  however,  quite  restored  till  April,  and  I  did  not 
allow  her  to  go  out  until  the  middle  of  the  month.  From  this  time 
until  Febraary,  1879,  her  health  continued  perfectly  good  and  she 
gained  flesh  and  color,  when  getting  chilled  from  skating  the  kidneys 
again  became  affected.  This  time  the  affection  was  at  once  detected, 
the  same  treatment  was  resorted  to  as  before,  and  a  more  rapid  cure 
was  brought  about.  Her  health  has  been  since  then  remarkably  good, 
and  lip  to  this  time  (December,  1882)  no  signs  of  a  return  of  the 
trouble  have  been  manifest  nor  does  a  microscopical  examination  of 
the  urine  show  the  existence  of  anything  abnormal. ' 


'  March  15th  of  thi»  year  (1883)  I  found  the  same  patient  to  be  suffering 
from  an  attack  of  nephritis  similar  to  the  first  one,  the  rational  symptoms 
and  the  phenomena  presented  by  microscopical  and  chemical  analysis  being 
almost  identical.  She  had  been  leading  during  the  winter,  which  was  a 
very  severe  one,  a  life  of  excessive  fatigue  in  the  way  of  social  dissipation, 
and  had  become  very  much  run  down.  While  the  nephritis  was  at  its 
height,  the  treatment  was  essentially  the  same  as  that  of  the  first  attack. 
After  tlie  more  severe  symptoms  had  disappeared,  and  simple  albuminuria 
alone  remained,  with  symptoms  of  very  mild  nephritis,  glonoine  gtt.  x^tt, 
four  times  daily,  and  the  muriate  of  iron  were  given,  with  the  effect,  appar- 
ently, of  bringing  about  restoration  of  health.  It  was  not,  however,  until 
the  latter  part  of  June  that  I  considered  this  consummation  to  be  effected. 
Since  then  to  the  present  time  (October  1st),  she  has  been  perfectly  well. 
As  a  matter  of  course,  the  nephritis  in  neither  attack  could  have  gone  so  far 
3,s  to  lead  to  cirrhosis. 


214  bright' S   DISEASE. 

The  cure  in  this  case  seems  clear.  That  this  case  was  one  of  inter- 
stitial nephritis  is  evident  from  the  rational  symptoms,  as  the  polynria 
and  low  specific  gravity  of  the  urine,  persistent  headaches,  compara- 
tive absence  of  nausea,  slight  oedema  only  of  eyelids,  the  gradual  and 
imperceptible  development  in  the  first  attack  without  any  assignable 
cause,  the  intermittent  albuminuria  and  the  phenomena  discernible  by 
the  microscoi)e.  It  was  the  "  primitive  chronic  interstitial  nephritis," 
so  designated  by  Charcot,  the  form  which  may  exist  unperceived  until 
its  magnitude  is  such  as  to  be  beyond  control — 

"  malum  qua  non  aliud  velocius  ullum  ; 

MoMUtate  viget,  viris  que  adquirit  eundo  " 

— sometimes  existing  without  apparent  deterioration  of  the  health,  and 
recognized  only  in  making  a  diagnosis  of  other  diseases,  as  of  the  eye 
or  heart.  The  case  of  the  jjrevious  patient  was  one  in  which  I  hoped 
for  recovery  ;  the  nephritis  was  distinctly  attributable  to  cold,  and,  as 
I  had  reason  to  know,  had  not  existed  more  than  six  weeks  before  it 
was  discovered.  The  two  cases  were  remarkably  alike  in  all  their 
features  as  regards  the  conditions  of  the  urine,  headaches,  debility, 
nervous  irritability,  etc.  The  treatment  was  nearly  identical,  the  dif- 
ference of  the  result  probably  being  the  constitutions  and  ages  of  the 
patients. 

I  am  not  able,  of  course,  to  say  exactly  how  long  the  nephritis  had 
existed  in  Case  XI.  before  my  discovery  of  it,  but  I  think  from  the  ra- 
tional symptoms  that  it  must  have  had  an  existence  of  two  to  three 
months. 

Case  XII. — Chronic  Interstitial  Nephritis  without  Albuminuria. — Mr. 

X ,  aged  fifty-eight,  a  professor  who  had  been  for  several  years 

overworked,  consulted  me  in  May,  1881.  He  suffered  from  insomnia, 
dyspepsia,  constipation,  and  severe  congestion  in  cervico-occipital  re- 
gion ;  it  was  also  a  case  of  ''brain  fag."  Eest,  several  applications  of 
the  thermo-cautery,  the  bromides,  phosj)hide  of  zinc,  strychnia,  etc., 
in  time  brought  about  great  relief.  Examination  of  the  urine  showed 
occasionally  a  hyaline  cast,  always  ej)ithelia  from  the  convoluted  and 
sometimes  from  the  straight  tubules  pf  the  kidney,  and  pus  corpus- 
cles, and  usually  considerable  oxalate  of  lime.  There  was  some 
polyuria. 

He  passed  the  months  of  July,  August,  and  September  at  the 
seaside  and  in  the  Adirondacks,  and  returned  very  much  better  in 
eveiy  way  except  the  kidneys.  In  these  I  found  no  change.  He  was, 
however,  by  no  means  cured  of  his  other  complaints,  and  was  obliged 


CHRONIC   INTERSTITIAL   NEPHRITIS — TREATMENT.      215 

to  relinquish  a  large  portion  of  liis  professional  duties.  A  constant 
improvement  in  his  health  went  on,  and  with  it  the  condition  of  the 
kidneys  improved.  Great  care  had  been  taken  in  his  diet :  animal 
food  in  moderation  had,  however,  been  allowed  once  daily,  and  the 
Turkish  and  Eussian  vajDor  baths  resorted  to  twice  a  week.  In  1882 
he  passed  the  months  of  Febraary  and  March  in  South  Carolina  and 
Florida.  On  his  return  he  took  at  various  times  arsenic,  nitric  acid, 
etc.,  and  continued  the  baths.  In  July,  he  went  to  Bourboule,  France. 
These  waters  are  thermal,  arsenical,  and  alkaline,  containing  the 
chloride  and  bicarbonate  of  soda.  They  are  situated  at  an  elevation  of 
two  thousand  five  hundred  feet,  and  as  the  urine  often  contained  too 
much  uric  acid,  seemed  to  be  very  well  suited  to  the  case.  He  took 
these  waters  a  month,  and  then  passed  a  month  in  the  Engadine. 

In  October  he  seemed  perfectly  well,  but  the  urine  invariably 
showed  ejoithelia  from  the  kidneys  with  jius  corpuscles,  though  fewer 
than  formerly.  He  has  been  able  to  work  as  usual  this  winter.' 
Every  possible  attention  has  been  paid  to  hygienic  conditions,  and  the 
baths  continued.  In  January,  Februaiy,  and  March,  1883,  the  urine 
was  found  to  be  absolutely  free  from  eveiything  abnormal,  so  far  as 
anything  pertained  to  the  kidneys,  and  I  believe  they  are  in  a  healthy 
condition.  I  never  foimd  the  slightest  trace  of  albumin  in  this  j^a- 
tient's  urine  but  ui^on  one  examination,  and  in  such  minute  quantity 
then,  Tanret's  test  showing  the  faintest  possible  cloud,  that  I  did  not 
consider  it  significant.  Now  I  believe  that  could  the  kidneys  of  this 
patient  be  examined  microscopically  organic  changes  would  be  found, 
as  perhaps  loss  of  some  ej^ithelia  and  their  replacement  by  endothe- 
lia,  slight  thickening  of  some  jDortions  of  connective  tissue,  etc.; 
nevertheless  I  think  the  inflammatory  process  has  been  at  the  end  of 
two  years  arrested — "  cured,"  perhaps  I  may  say. 

The  father  of  this  gentleman  had  died,  three  years  be- 
fore, of  chronic  croupous  nephiitis,  and  I  believe  the 
recognition  of  this  case  in  its  inception,  and  the  re- 
course to  proper  measures,  prevented  the  development 
of  a  grave  and  intractable  interstitial  nephritis.  I  am 
not  able  to  attribute  the  accomplishment  of  any  great 
benefit  to  any  one  remedy.  The  circumstance  of  his 
being  able  and  willing  to  resort  to  any  course  recom- 

1  Written  in  December,  1882. 


216  bright' S   DISEASE. 

mended  by  me  was,  however,  of  material  benefit  in  the 
treatment.  It  may  be  that  the  kidneys  got  well  pari 
passu  with  the  cure  and  improvement  of  the  rest  of  his 
system.  The  constitution  of  this  patient  was  remarka- 
bly good.  Equal  success,  however,  has  by  no  means 
always  followed  even  the  early  discovery  of  mild  inter- 
stitial nephritis,  although  albumin  might  be  absent,  as 
other  cases  of  a  light  form  have  resisted  treatment ; 
nevertheless,  I  believe  that  when  the  constitution  is 
good,  the  case  is  recognized  at  an  early  period,  and 
there  exists  every  advantage  necessary  to  treatment, 
recovery  may  be  hoped  for.  And  it  is  upon  the  early 
discovery  of  the  nephritis  that  the  opportunity  of  effect- 
ing a  cure  most  depends.  I  believe  that  the  tendency 
of  many  mild  cases  of  nephritis  in  healthy  subjects  is 
toward  recovery  if  other  derangements  of  the  health 
disappear ;  I  have  often  known  such  cases  to  recover 
without  treatment  of  them.  The  usually  mild  nephritis 
without  albuminuria,  which  is  ordinarily  present  in 
phthisis,  would  almost  always  disappear  if  the  latter 
recovered.  The  interstitial  nephritis  arising  from  cys- 
titis usually  disappears  with  the  cure  of  the  latter. 
And  as  inflammations  recover  entirely  in  other  organs, 
why  should  it  be  considered  almost  as  a  rule  that  inter- 
stitial nephritis  cannot  be  cured  ?  or  perhaps  I  should 
say,  recover?  It  is  not  always  an  affair  of  nephritis — it 
is  also  a  matter  of  concomitant  conditions,  such  as  the 
amount  of  inflammation,  time  of  its  existence,  constitu- 
tion of  the  patient,  and  the  opportunities  of  employing 
the  most  suitable  means  of  cure. 

The  corrosive  chloride  of  mercury,  though  it  is  un- 
doubtedly more  suited  to  croupous  nephritis,  will  some- 
times be  found  more  useful  than  calomel  in  interstitial 
nephritis ;  it  may  be  that  in  those  cases  that  it  helps  the 
affection  of  the  epithelia  predominates.  At  all  events, 
I  have  found  it  useful  in  some  cases  where  the  latter 


CHRONIC   INTERSTITIAL   NEPHRITIS — TREATMENT.      217 

remedy  did  not  prove  so.  When  the  condition  of  cir- 
rliosis  is  reached,  neither  of  these  remedies  is  capable 
of  relieving  it,  but  it  must  be  considered  that  even  in  cir- 
rhosis there  are  frequently  recurring  and,  indeed,  some- 
times constantly  existing  acute  conditions,  and  if  estab- 
lished organic  pathological  conditions  are  not  benefited, 
further  inroads  may  be  prevented  and  fresh  inflamma- 
tions arrested. 

The  iodide  of  potassium  would  seem,  on  account  of  its 
known  diuretic  and  resolvent  properties,  to  be  likely  to 
be  of  use  in  many  conditions  of  interstitial  nephritis. 
That  it  often  produces  "absorption  of  inflammatory  effu- 
sions and  inflammatory  thickening  of  organs"  (Ringer) 
is  conceded,  but  except  in  those  cases  of  nephritis  due 
to  the  causology  I  shall  mention,  I  have  not  found  it  of 
very  great  value,  except  by  virtue  of  its  diuretic  prop- 
erties, and  those  cases  could  have  been  helped  as  well  by 
other  remedies. 

Bartels  says:  "Starting  on  the  supposition  that, 
whatever  preconceived  opinion  we  may  entertain  of  the 
nature  of  the  process  of  renal  contraction,  we  must 
admit  that  in  every  instance  we  have  to  deal  with  a 
growth  of  interstitial  connective  tissue  which  exercises 
a  prejudicial  effect  upon  the  true  glandular  cells,  I 
aimed  to  restrain  this  process  of  proliferation,  and  with 
this  intent  turned  my  attention  to  the  employment  of 
iodide  of  potassium.  This  substance  recommends  itself 
to  us  in  so  many  cases  of  hyperplastic  connective  tissue 
growth  that  it  appeared  to  me  to  deserve  more  confi- 
dence than  any  other  medicament  in  this  particular  af- 
fection likewise.  I  give  iodide  of  potassium,  in  solu- 
tion, to  the  extent  of  1.5  to  2  grammes  {from  20  to  30 
grains)  daily,  and  continue  the  use  of  this  salt  for  an 
indefinite  period,  and  I  can  assure  my  readers  that  I 
have  never  seen  any  prejudicial  effects  from  the  use  of 
this  substance  taken  uninterruptedly  for  many  months. 


218  bright' S   DISEASE. 

As  to  any  direct  influence  of  the  drug  upon  the  quantity 
or  quality  of  tlie  urine  (except  showing  its  own  pres- 
ence), I  have  remarked  none  whatever."  ("Cyclopse- 
dia,"  Ziemssen,  vol.  xv.,  p.  490.) 

It  does  not  seem  to  me,  in  my  experience,  that  it  is 
capable  of  producing  resolution  of  plastic  inflammation 
in  the  kidneys,  or  absorption,  unless  given  in  very  large 
doses,  and  in  the  acute  recurrences  and  new  effusions, 
which  are  the  only  conditions  which  any  remedy  can 
cure  in  chronic  nephritis.  In  this  latter  affection  an 
anaemic  condition  and  exhaustion  usually  exist,  which 
are  increased  by  large  doses  of  this  alkali.  I  have 
known  75  grains  to  be  given  daily  in  an  advanced  stage 
of  interstitial  nephritis,  with  the  effect  of  greatly  in- 
creasing the  previous  debility.  In  acute  nephritis  I 
have  found  it  of  more  use ;  sometimes,  I  thought,  bring- 
ing about  resolution,  diuresis,  and  diminution  of  albu- 
min. In  chronic  interstitial  nephritis,  however,  diuret- 
ics are  very  seldom  required. 

In  nephritis  accompanying  or  caused  by  syphilis, 
however,  I  have  known  the  iodide  to  effect  a  cure  ;  a 
notable  instance  is  the  case  of  so-called  waxy  kidney 
described  by  Bartels  (in  Ziemssen).  In  syphilis  it  should 
be  given  in  large  doses. 

In  the  nephritis  produced  by  lead-poisoning  the  iodide 
of  potassium  will  undoubtedly,  by  promoting  the  excre- 
tion of  lead,  be  of  use,  and  in  the  gouty  kidney  or  the  ne- 
phritis of  rheumatic  gout  I  have  found  it  of  great  value. 
Arsenic  has  sometimes  proved  beneficial  in  diminishing 
albuminuria  and  in  relieving  headaches  and  nausea.  It 
is  a  mineral  which  under  some  circumstances  improves 
the  quality  of  the  blood  and  increases  nervous  strength. 
I  believe  it  does  this  by  promoting  the  valid  action  of 
the  assimilative  system  or  correcting  disturbances  of 
certain  organs  whose  derangement  contributes  to  the 
development  of  debility  and  anaemia.     From  its  patho- 


CHROIS'IC   INTERSTITIAL   NEPHRITIS — TREATMENT.      219 

logical  effects  u^^oii  the  kidneys  it  sliould,  in  inflamma- 
tion of  them,  have  a  very  great  influence,  unfavorable  or 
favorable.  Given  in  certain  doses  I  have  never  known 
the  former  to  result,  but  often  the  latter.  I  usually 
give  yJ-y-  of  a  grain  several  times  daily.  I  have  given, 
however,  4-^  of  a  grain  at  a  dose. 

Lead,  according  to  Geo.  Lewald,'  has  been  found  to 
diminish  the  secretion  of  albumin  in  the  urine  and  to 
increase  the  quantity  of  urine.  Neither  the  diminution 
of  the  former  nor  the  increase  of  the  latter  appeared  to 
hold  any  relation  to  the  quantity  of  lead  administered. 

According  to  the  homoeopathic  materia  medica  it 
should  be  especially  useful  in  this  disease,  though  I 
have  been  able  to  find  but  one  case  where  its  usefulness 
is  authenticated.     I  have  not  derived  benefit  from  it. 

Prof.  S.  A.  Jones,  of  the  University  of  Michigan,  took 
charge  of  the  case  of  a  patient,  a  man  fifty-two  years  of 
age,  a  lawyer,  with  cirrhosis  of  the  kidneys.  Had  been 
suffering  for  the  last  three  years.  There  was  frequent 
urination  and  some  hyaline  casts.  No  oedema ;  some 
uric  acid. 

Lead  was  administered  in  small  doses  vt^ithout  other 
remedies.  A  cure  was  not  effected,  but  such  an  amount 
of  benefit  was  conferred  as  to  enable  the  patient  to  re- 
sume and  continue  work  for  a  year.  He  died  two  years 
after,  however. 

It  is  possible  that  this  mineral,  which  has  such  a  pois- 
onous effect  upon  the  kidneys,  may  yet  be  found  to 
possess  curative  properties  in  affections  of  them. 

Turpentine  might  be  found  of  use  where  there  is  a 
feeble  state  of  the  renal  circulation  ;  it  should  be  given 
in  drop  doses  to  an  adult,  two  or  three  times  daily.  Its 
effect  upon  the  kidney  and  indications  for  its  use  seem 
very  much  the  same  as  cantharides. 


'Riuger  :  Handbook  of  Therapeutics,  p.  229.     American  Edition. 


220  beight's  disease. 

The  chloride  of  gold  has  proved  of  great  value  in  chronic 
interstitial  nephritis.  Under  its  use  I  have  often  known 
the  albumin  to  diminish  and  disappear.  Aside  from  its 
astringent  properties  I  can  advance  no  theory  of  its 
beneficial  action  except  that  it  may  exert  an  influence 
through  the  medium  of  the  spinal  cord  and  renal  nerves, 
experience  having  shown  it  to  be  a  nervous  stimulant 
and  tonic  of  great  importance.  I  have  found  it  of  great 
value  in  affections  of  the  genito-urinary  system  unac- 
companied by  inflammation,  as  in  seminal  weakness, 
loss  of  power  of  the  sphincter  of  the  bladder,  the  various 
degrees  of  impotence,  etc.  At  all  events,  its  usefulness 
in  chronic  nephritis  has  sometimes  been  unmistakable, 
and  it  is  likely  to  prove  still  more  useful  if  the  patient 
suffer,  as  is  usual,  from  nervous  symjDtoms,  hypo- 
chondriasis, irritability,  vertigo,  etc.  The  chloride  of 
gold  and  soda  seems  to  produce  very  much  the  same 
effect  as  the  chloride  of  gold  simply. 

I  administer  these  remedies  in  doses  of  from  -^\-^  to  yV 
of  a  grain  three  or  four  times  daily,  or  even  of tener. 

The  tannate  of  sodium  has,  in  my  experience,  been 
of  use  in  diminishing  albuminous  exudations,  though 
the  accomplishment  of  this  simply  in  chronic  intersti- 
tial nephritis  is  not  necessarily  a  great  desideratum, 
unless  the  albumin  be  lost  in  considerable  quantity,  as 
the  mere  cessation  of  albuminuria  does  not  always  de- 
note an  improvement  in  the  nephritis. 

Of  coiwallaria  I  have  already  spoken.  It  is  of  great 
use  when  there  is  a  feeble  action  or  organic  affection  of 
the  heart,  and  it  undoubtedly  possesses  some  diuretic 
properties.  As  it  is  not  cumulative  it  may  in  some 
cases  be  given  more  freely  than  digitalis. 

Nitro-glycerine  is  of  value  when  there  is  great  arte- 
rial tension,  violent  action  of  the  heart  with  hypertro- 
phy and  polyuria,  although  I  have  known  it,  in  some  of 
these  conditions,  to  be  valueless.     In  the  case  referred  to 


CHRONIC   INTERSTITIAL   NEPHRITIS — TREATMENT.      221 

on  p.  186,  although  I  believe,  after  repeated  examina- 
tions, that  nephritis  was  slight  and  secondary  to  other 
derangements,  the  pulse  was  hard  and  tense,  there  was 
increased  and  violent  impulse  of  the  heart,  and  exces- 
sive flow  of  urine,  for  two  weeks  at  least  24  quarts  being 
passed  every  twenty-four  hours.  Under  the  influence 
of  this  remedy,  a  drop  of  a  one  per  cent,  solution  being 
given  four  times  daily,  the  urine  fell  from  12  to  5  quarts 
daily.  Its  use  had  to  be  suspended  in  three  weeks,  as 
it  produced  distressing,  "bursting"  headaches. 

The  speciflc  gravity  of  the  urine  in  this  case  was,  while 
the  urine  was  so  abundant,  998  to  1003  ;  afterward  it 
reached  1005.  There  had  been  but  very  slight  albumi- 
nuria, at  most  not  more  than  g^^-g-  of  one  per  cent.  The 
microscope  had  shown  no  indications  of  nephritis  except 
a  few  epithelia  from  the  convoluted  tubules.  As  this 
patient  came  under  my  care  only  a  few  days  before  my 
departure  abroad  in  July,  and  he  has  been  under  my 
care  again  only  for  ten  days,  I  hope  at  a  future  time  to 
present  fuller  details  of  this  case,  which  is  full  of  inter- 
est from  every  point  of  view. 

Digitalis  is  a  valuable  diuretic  where  the  diminished 
flow  of  urine  is  dependent  upon  enfeebled  action  of  the 
heart,  and  may,  like  convallaria,  be  administered  in  sim- 
ilar cardiac  conditions.  The  comparative  spheres  and 
modes  of  action  of  these  two  remedies  in  cardiac  de- 
rangements are  as  yet  not  strictly  defined.  Digitalis 
has  the  merit  of  not  being  an  irritant  diuretic.  It  is 
more  fully  spoken  of  in  Chapter  XXI. 

Iron,  especially  the  chloride,  is  often  of  use  in  chronic 
interstitial  nephritis ;  it  is  especially  so  in  enfeebled 
muscular  action  of  the  heart,  alone  or  in  combination 
with  digitalis.  Iron  is  ordinarily  of  most  use  in  pro- 
portion as  the  hepatic,  digestive,  and  assimilative  func- 
tions are  normal,  and  as  the  albuminous  phenomena  are 
remote  from  or  independent  of  recent  and  fresh  con- 


222  bright' S   DISEASE. 

gestion  or  inflammation.  That  it  may  be  of  use  in  con- 
trolling albuminuria  is  shown  in  Case  YI.,  and  in  the 
following  case,  in  which  it  was  given  in  combination 
with  quinine.  Of  its  possible  mode  of  action  I  have 
spoken  in  Chapter  XXI. 

Case  XIII. — X ,  a  carpenter,  aged  twenty-four  ;  naturally  of  a 

good  constitution  ;  consulted  me  on  account  of  frequent  urination  and 
debility.  Had  been  suffering  for  several  weeks.  Urine  albuminous, 
witli  epithelia  from  tlie  kidney  and  pus  corpuscles.  Had  had  fever 
and  ague  and  was  somewhat  ansemic.  Gave  12  drops  chloride  iron 
after  and  3  grains  quinine  before  each  meal. 

Under  the  influence  of  these  remedies,  rest,  and  appro- 
priate diet,  the  albumin,  epithelia,  etc.,  disappeared 
entirely  at  the  end  of  some  weeks.  That  this  was  a 
comparatively  mild  case  of  interstitial  nephritis  there  is 
no  doubt,  but  "mild"  only  in  that  no  symptoms  of 
ursemic  poisoning  had  declared  themselves.  I  did  not 
expect  from  these  remedies  the  benefit  that  resulted. 
That  the  chloride  (and  likewise  the  phosphate)  of  iron 
is,  however,  of  use  in  controlling  albuminous  exuda- 
tions I  have  many  times  found,  and  I  believe  them  to 
be  of  value  in  subacute  nephritis.  The  influence  of  the 
chloride  of  iron  upon  the  circulation  of  the  kidneys  is 
well  known  ;  as  to  the  exact  influence  of  the  quinine  I 
am  not  so  sure.  It  is,  however,  of  service  where  there 
has  been  much  loss  of  albumin,  and  I  have  often  found 
it  useful  in  albuminuria. 

The  value  of  nitric  and  phosphoric  acid  I  have  already 
referred  to.  (See  Chapter  XXI.)  They  undoubtedly 
aid  greatly  sometimes  in  diminishing  albuminous  ex- 
udations. 

It  thus  appears  that  the  number  of  remedies  which, 
have  alone  been  known  to  prove  curative  in  chronic 
interstitial  nephritis  is  not  numerous.  N"evertheless, 
these,  intelligently  administered,  conjoined  with  other 


CIIEOlSriC   INTERSTITIAL   NEPHRITIS — TREATMENT.      223 

measures  and  remedies,  and  aided  by  an  early  diagnosis, 
may  effect  a  cure  in  many  cases. 

Cantharldes,  of  which  I  usually  give  a  fiftieth  or  one- 
hundredth  of  a  grain  at  a  dose,  prepared  in  the  form  of 
a  trituration  with  sugar  of  milk,  has  sometimes,  in  con- 
junction with  corrosive  sublimate  or  calomel,  brought 
about  a  subsidence  of  the  albuminous  secretions  when 
the  two  latter  remedies  seemed  inefla.cacious.  In  one  or 
two  instances  I  have  produced  by  it  alone,  diminution 
of  albuminuria.  Of  the  possible  mode  of  its  action  I 
have  already  spoken.  It  seems  more  calculated  to  be 
of  use  in  croupous  nephritis.  As  a  diuretic,  however, 
its  virtues  are  more  apparent.  I  employ  it  more  as  the 
case  recedes  from  the  acute  character  ;  being  most  ser- 
viceable if  there  be  apparently  a  weak  condition  of  the 
renal  circulation. 

"When  we  consider  the  close  analogy  between  the 
symptoms  and  pathology  of  the  gouty  and  cirrhotic 
kidney,  we  may  hope,  in  the  latter,  to  derive  benefit 
from  the  same  class  of  remedies  and  treatment  that  is 
useful  in  gout.  In  chronic  gout,  and  sometimes,  though 
rarely,  in  acute  paroxysms  of  gout,  small  quantities  of 
albumin  are  generally  excreted.  The  gouty  kidney  al- 
most always  presents  the  features  of  interstitial,  seldom 
of  croupous  nephritis. 

When  a  gouty  paroxysm  is  developed  there  is  usually 
an  excess  of  uric  acid,  preceding,  or  produced  by,  the 
renal  disturbance,  with  diminished  alkalinity  of  the 
blood,  preventing  its  holding  the  urate  of  soda  in  solu- 
tion. This  acidity  m.^j  be  and  is  generally  due  to  im- 
paired activity  of  the  cutaneous  or  hepatic  functions,  or 
to  the  malassimilation  of  food. 

We  may,  recognizing  the  important  rolethsit  the  liver 
performs  in  developing  gouty  and  with  it  renal  disturb- 
ances, often  hope,  where  the  kidney  disease  is  accom- 
panied by  marked  hepatic  derangement,  in  view  of  the 


224  bright' S   DISEASE. 

dependence  of  tlie  former  npon  tlie  latter,  that  the  same 
class  of  remedies  that  is  likelj"  to  be  serviceable  in  af- 
fections of  the  liver  may  ameliorate  the  morbid  condi- 
tion of  the  kidney.  And  this,  indeed,  we  often  find  to 
be  the  case. 

"Where  there  are  marked  hepatic  symptoms  benefit 
Avill  often  be  derived  from  treatment  appropriate  to 
liver  troubles.  I  place  among  the  most  valuable  ac- 
cessories in  such  cases  certain  mineral  springs,  notably 
Carlsbad,  Marienbad,  and  Yichy.  The  latter  vs^ater, 
whose  chief  constituent  is  the  bicarbonate  of  soda,  is  of 
use  where  the  urine  is  acid,  where  the  debilitj^  is  not 
great  and  the  functions  of  the  liver  are  markedly  de- 
ranged. According  to  Garrod,  it  is  most  useful  in 
acute  gout.  It  is  indicated  where  an  excess  of  uric 
acid  is  formed  in  the  system.  In  the  difficulty  on  the 
part  of  the  kidneys  of  excreting  the  uric  acid,  Yichy  is 
not  serviceable.  It  aids  in  the  formation  of  certain  bil- 
iary acids  and  neutralizes  acidit}^  of  the  urine  and  ex- 
cess of  uric  acid  in  the  blood. 

The  icaters  of  Carlsbad  iJiprudel2jn.dL  Scfilossbrunnen), 
whose  efficacy  depends  mainly  upon  the  sulphate  of 
soda,  together  with  the  carbonate,  are  of  use  more  par- 
ticularly in  jDroportion  as  the  kidnej^  affection  is  directly 
dependent  upon  that  of  the  liver,  though  they  are  of 
value  in  conditions  characterized  by  the  existence  of 
uric  acid  in  excess.'  The  value  of  these  waters  in 
chronic  fatty,  enlarged  livers,  in  gall-stones,  etc.,  is  too 
well  known  to  expatiate  upon.  I  have  in  mind  one 
case  of  frequently  recurring  albuminuria  in  chronic 
gout,  with  great  congestion  and  pain  in  the  liver,  ap- 
parently quite  cured  by  two  seasons  at  Carlsbad. 

The  Buffalo  LitMa  Springs  water ^  "ISTo.  2,"  in  Vir- 

'  It  is  but  very  recently  that  it  has  been  discovered  that  the  Sprudel  con- 
tains four-fifths  and  the  Schlossbrunuen  two-fifths  of  a  grain  of  the  carbon- 
ate  oflithia  to  the  gallon. 


CHKOlSriC   INTERSTITIAL   NEPHEITIS — TREATMENT. 

ginia,  should  be,  and  lias,  indeed,  proved  of  use  where 
the  uric  acid  diathesis  is  marked. ,  The  following  is  the 
analysis  of  the  water  made  by  Prof.  Wm.  P.  Tonry,  of 
the  Maryland  Institute,  Baltimore  : 

[Eesults  expressed  in  grains  per  imperial  gallon.  1 

Springs  No.  2.  Grains. 

Sulphate  of  magnesia 0.885 

alumina 9.067 

lime 33.067 

Carbonate  of  potash . .    , 29.300 

Bicarbonate  of  lime 14.963 

lithia 2.250 

baryta 1.750 

iron 0.300 

Chloride  of  sodium 4.921 

silica 1.873 

Phosphoric  acid traces 

iodine traces 

lie  matter small  amount 


Total  number  of  grains  per  gallon 98.376 

Sulphuretted  hydrogen 8.3  cubic  in. 

Carbonic  acid  gas 59.2         " 

Its  alkaline  constituents,  and,  most  of  all,  the  lithia, 
which  it  contains  in  considerable  proportions,  make  this 
water  exceedingly  valuable  where  alkaline  waters  are 
needed.  The  power  of  lithia  as  a  solvent  of  uric  acid  is 
well  known.  The  lithia  waters  are  especially  suited  to 
the  gouty  kidney,  and  in  this,  except  so  far  as  any  di- 
rect influence  upon  the  cirrhosis  is  concerned,  sometimes 
prove  exceedingly  beneficial.  The  iron  contained  in  the 
Carlsbad  and  Buffalo  waters  adds  greatly  in  anaemic  con- 
ditions to  their  value.  As  a  rule,  the  interstitial  nephri- 
tis of  gout,  which  Charcot  calls  the  "gouty  kidney,"  is 
accompanied  by  an  excess  of  uric  acid  in  the  blood, 
whether  causing  or  caused  by  the  non-eliminative  power 
of  the  kidney  ;  and  although  too  much  cannot  be  ex- 
15 


226  beight's  disease. 

pected  from  waters  in  relieving  renal  congestion  or  in- 
flammation, it  is  often  of  tlie  highest  importance  to 
diminish  the  excess  of  uric  acid,  as  severe  crises  and 
ursemic  symptoms  may  thereby  be  prevented.  I  think 
in  ordinary  albuminuria,  without  advanced  or  marked 
signs  of  nephritis,  the  Buffalo  lithia  water  is  sometimes 
of  use ;  but  cannot,  so  far  as  the  action  upon  the  kid- 
neys is  concerned,  recognize  its  applicability  generally 
in  chronic  interstitial  nephritis,  with  or  without  cirrho- 
sis, characterized  by  low  specific  gravity  of  the  urine,  a 
deficiency  of  uric  acid,  and  perhaps  by  polyuria.  It  is 
likely  to  be  of  more  value  in  nephritis  where  there  is 
torpidity  of  the  liver,  acid  dyspepsia,  etc.,  and  in  cases 
characterized  by  a  rheumatic  diathesis. 

The  Bilin  loater  of  Bohemia,  which  is  imported  here 
without  deterioration,  containing  .110  grain  of  lithia 
and  23  grains  of  the  carbonate  of  soda  to  the  pint, 
together  with  the  carbonates  of  magnesia,  iron,  sulphate 
of  potash,  soda,  and  alumina,  has  proved  of  great  value 
in  nephritis  where  the  uric  acid  diathesis  existed,  partic- 
ularly if  complicated  with  hepatic  derangements.  It  is 
a  valuable  lithine  water,  and  has  many  of  the  proper- 
ties both  of  the  Carlsbad  and  Yichy  waters. 

The  Ballston  Spa  (United  States  Spring)  water  con- 
tains a  very  large  amount  of  lithia  (.950  grain  to  the 
pint),  together  with  0.208  grain  of  iron.  It  should  be 
of  use  in  many  cases  of  nephritis  attended  with  hepa- 
tic and  digestive  derangements.  The  same  may  be  said 
of  several  of  the  Saratoga  waters,  some  of  them  contain- 
ing lithia  in  considerable  amount. 

The  waters  of  Contrexmlle  (France)  have  proved  of 
value.  They  are  calcic,  alkaline,  and  slightly  ferrugi- 
nous and  arsenical ;  they  are  of  use  sometimes  in  diabe- 
tic complications,  and  especiall}^  in  chronic  cystitis. 
They  are  decidedly  diuretic. 

The  waters  of  Pougues  (France),   sodic-bicarbonate 


CHRONIC   INTERSTITIAL   NEPHRITIS — TREATMENT.      227 

and  slightly  femiginous,  are  somewliat  similar  to 
(tliough  not  arsenical)  the  ^Yaters  of  Contrexville.  Both 
these  waters  can  be  obtained  here. 

It  would  seem  as  if  the  numerous  excellent  and  easily 
taken  effervescent  salts  of  litliia  now  in  use,  as  the  ben- 
zoate,  citrate,  etc.,  should  be  serviceable  in  the  uric  acid 
diathesis.  In  a  coarse  way  they  certainly  can  do  good 
by  bringing  about  alkalinity  of  the  urine ;  still  in  chron- 
ic nephritis  I  should  not  employ  them  except  as  tem- 
porary measures.  The  greater  efficacy  of  medicinal 
substances  as  found  in  natural  waters  is  well  known, 
waters  which  contain  mineral  constituents  in  feeble  pro- 
portions conferring  undoubted  benefit  in  disease. 

The  Marienhacl  waters  very  much  resemble  those  of 
Carlsbad,  except  that  they  contain  twice  as  much  sul- 
phate of  soda,  and  are  cold,  while  the  latter  are  warm. 
The  Marienbad  also  contain  more  iron  than  the  Carls- 
bad. 

Franzensbad^  like  the  above  two,  in  Bohemia,  contains 
more  sulphate  of  soda  than  Carlsbad,  and  less  than 
Marienbad.     It  is  valuable  in  the  same  class  of  troubles. 

Tarasp  is  situated  in  the  lower  Engadine,  at  an  eleva- 
tion of  4,000  feet;  the  waters  of  the  springs  contain  a 
large  quantity  of  sulphate  of  soda,  16  grains,  and  also 
29  grains  of  oommon  salt,  together  with  27  of  carbonate 
of  soda  to  the  pint ;  they  partake,  therefore,  of  the  prop- 
erties of  Carlsbad  and  Yichy  combined. 

The  waters  of  St.  Nectaire,  in  Central  France,  are 
mildly  alkaline  and  ferruginous.  I  think  them  of  use  in 
certain  cases  of  nephritis  not  too  far  advanced.  They  are 
situated  at  an  elevation  of  4,500  feet,  and  consequently 
combine  the  advantage  of  mountain  air.  They  can  be 
reached  in  about  thirteen  hours  from  Paris. 

The  waters  of  Mont  Dore.,  fifteen  miles  from  St. 
Nectaire  (arsenical  and  ferruginous),  at  an  elevation  of 
about  3,500  feet,  may  be  resorted  to  in  somewhat  similar 


228  beight's  disease. 

cases  to  tliose  likely  to  be  benefited  by  the  waters  of  St. 
Nectaire. 

La  Bourhoule^  at  an  elevation  of  2,400  feet,  also  in  the 
same  department  (Pay  de  Dome),  iron,  strongly  arseni- 
cal, containing  four-fifths  of  a  grain  of  arsenious  acid  to 
the  gallon,  and  alkaline  springs,  are  perhaps  of  more 
use  than  either  of  the  preceding  in  albuminuria  and 
in  the  gouty  kidney,  and  in  nephritis  caused  by  an 
accompanying  paludal  poisoning ;  they  are  of  especial 
value  in  the  cachexia  produced  by  the  latter  cause. 
The  waters  have  considerable  diuretic  properties.  I 
have  known  patients  suffering  from  chronic  interstitial 
nephritis  greatly  benefited  by  them.  The  waters  of 
KreutznacJi,  near  the  Rhine  (chloride  of  sodium,  iron, 
bromide,  and  iodine),  are  of  use  where  iron  seems  of 
value ;  and  some  of  the  milder  chalybeate  springs  of 
Saratoga,  some  of  them  containing,  as  already  stated, 
considerable  lithia,  should,  in  anaemic  conditions,  and 
where  iron  is  of  use,  be  serviceable,  especially  in  the 
uric  acid  diatheses  and  in  torpid  livers.  I  have  always 
thought  that  the  large  quantity  of  the  carbonate  of 
lime,  however,  which  they  contain  (most  of  them  8 
to  14  grains  to  the  pint),  and  which  is  found  only  in 
minute  quantities  in  most  of  the  European  springs, 
militates  against  their  utility  in  affections  of  the  liver 
and  kidneys. 

Wildungen,  in  Germany,  about  six  hours  from  Frank- 
fort (calcic,  alkaline,  and  ferruginous),  are  suited  to 
somewhat  the  same  cases  as  St.  Nectaire ;  they  are  of 
additional  value  in  chronic  cystitis. 

I  am  certain  that  in  nephritic  disorders  the  employ- 
ment of  mineral  waters  has  not  received  the  attention  it 
deserves.  I  have  had,  in  numerous  visits  to  the  Old 
World,  man}'-  opportunities  of  observing  their  beneficial 
effects.  The  spas  of  the  Continent  have  the  advantage 
of  having  each  been  analyzed  quantitatively  and  of  liav- 


CHRONIC   INTERSTITIAL   NEPHRITIS — TREATMENT.      229 

ing  been  well  tried.  It  is  only  a  matter  of  study  to  ob- 
tain macli  benelit  from  them  from  a  therapeutic  point  of 
view,  but  tlie  same  discrimination  must  be  observed  in 
prescribing  them  as  in  selecting  other  medicines,  super- 
added to  which  must  be  considered  the  suitability  of 
the  location  and  climate  to  the  patient.  Among  the 
most  useful  works  on  mineral  springs  and  health  re- 
sorts may  be  mentioned  those  of  Durand-Fardel  and 
Constantin  James,  both  of  Paris;  Ad.  Joanne,  "Les 
Bains  d' Europe"  ;  Madden,  "Health  Resorts,"  a  fair 
compilation  ;  a  very  good  work  by  an  American  author, 
Dr.  Walton,  "Mineral  Springs  of  the  United  States  and 
Canada;"  Dr.  MacPherson,  "The  Baths  and  Wells  of 
Europe,"  London  :  Macmillan  &  Co.;  also  Eug.  le  Bret, 
"  Manuel  Medical  des  Eaux  Minerales,"  Paris,  a  most 
excellent  work  ;  "  The  Mineral  Waters  of  Europe,"  by 
Drs.  Tichborne  and  Prosser  James,  London,  1883. 

Diuretics. — An  essential  feature  of  interstitial  ne- 
phritis is  that  not  only  are  anasarca  and  oedema  usually 
absent,  but  the  flow  of  urine  is,  on  an  average,  in  excess 
of  that  of  the  healthy  kidney  ;  consequently  the  occa- 
sions for  the  use  of  diuretics  are  rare.  In  enfeebled 
conditions  of  the  system,  however,  and  of  the  heart, 
they  are  sometimes  needed,  and  in  advanced  stages  of 
interstitial  nephritis  the  healthy  tissue  of  the  kidney  is 
so  limited  that  the  quantity  of  urine  falls  below  the 
average. 

Broom,  juniper,  and  simple  water  increase  the  amount 
of  urea,  and  they  become  endowed  with  increased  value 
in  proportion  as  there  is  a  diminution  of  urea  in  the 
urine.  The  alkalies,  their  carbonates,  as  the  carbonate, 
bitartrate,  and  acetate  of  potash  and  urea,  should  be  of 
use  as  diuretics  when  the  secretion  of  urea  falls  below 
the  normal.  These  remedies  act  not  only  as  hydra- 
gogue  cathartics,  but  as  renal  depurants.  (See  "Diure- 
tics," Chapter  XXL) 


230  beight's  disease. 

The  alkaline  diuretics  cannot  be  employed  much  if 
there  have  been  a  great  loss  of  albumin  and  the  blood  is 
verj^  much  defibrinated,  nor  in  conditions  of  great  de- 
bility or  of  feeble  digestion. 

In  enfeebled  muscular  and  nervous  action  of  the 
heart,  strychnia,  digitalis,  iron,  convallaria,  and  the 
fluid  extract  of  coca  are  all  to  be  considered. 

The  Treatment  of  Various  Urcemic  Accidents. — Of 
these  may  be  mentioned,  as  among  the  most  trouble- 
some, convulsions  and  distressing  itching,  and  prurigo. 

For  the  relief  of  the  former  the  usual  treatment  of 
epileptic  seizures  must  be  employed  ;  but  I  think  benefit 
may  be  often  derived  from  the  introduction  of  a  supposi- 
tory containing,  for  an  adult,  5  grains  of  bromide  of  cam- 
phor, with  25  or  30  grains  of  the  hydrate  of  chloral. 

For  the  relief  of  the  intense  itching  I  have  found 
nothing  comparable  to  an  infusion  of  coniuni  leaves, 
prepared  by  steeping  a  drachm  to  a  quart  of  water. 

Lotions  or  ointments,  containing  3  to  5  minims  of 
dilute  hydrocyanic  acid,  may  be  employed.  I  have  also 
found  a  lotion  of  staphysagria  of  great  use,  and  an  oint- 
ment containing  five  per  cent,  of  naphthol  has  proved 
especially  serviceable. 

Danger  of  Ancestlietics  in  Nephritis. — That  this  dan- 
ger may  exist  I  think  is  shown  in  a  paper  by  Dr.  R. 
Yan  Santvoord,  in  the  Medical  Record^  March  10, 1883. 
He  shows  from  various  authorities,  particularly  Mr. 
Lawson  Tait,  that  the  administration  of  ether  will  pro- 
duce suppression  of  the  urinary  secretion.  Although 
ether  and  chloroform  are  often  without  injury  adminis- 
tered in  nephritis,  their  use  should,  I  think,  be  avoided 
if  there  be  anuria  or  extensive  structural  changes  in  the 
kidneys. 


CHAPTER  XXIY. 

TREATMENT  OF  CHRONIC  CROUPOUS  NEPHRITIS. 

After  tlio  consideration  that  lias  been  given  to  the 
treatment  of  acute  nephritis  and  chronic  interstitial  ne- 
phritis, there  is  comparatively  little  to  be  added  under 
the  heading  of  this  chapter  that  may  not  be  included  in 
the  last-named  diseases.  Chronic  croupous  nephritis  is, 
I  think,  much  less  common  than  the  cirrhotic  kidney, 
and  when  it  exists  usually  produces  the  large  white  kid- 
ney, the  fatty,  or  the  contracted  kidney,  each  of  which 
is  in  its  nature  incurable. 

Nevertheless  there  are  forms  and  gradations  of  this 
chronic  affection  which  are  accompanied  by  severe 
dropsy  and  apparently  entire  breaking  down  of  the 
system,  which  are  cured ;  probably  permanent  organic 
changes  not  having  been  fully  established.  Unless, 
therefore,  unmistakable  evidences  are  found  of  incur- 
able organic  changes,  and  unless  other  conditions  of  the 
system  militate  against  the  possibility  of  recovery,  the 
cure  of  the  patient  is  always  to  be  hoped  for  and  at- 
tempted. 

It  is  within  my  own  experience,  as  well  as  that  of 
others,  that  cases  are  cured,  and  sometimes,  too,  where 
the  rational  signs  and  the  enfeebled  state  of  the  patient 
seemed  to  extend  but  faint  promise  of  recovery.  Some 
cases  I  will  give  later.  There  is  the  advantage  in  the 
management  of  this  affection,  that  it  is  usually  discov- 
ered with  a  certain  degree  of  readiness  and  prompti- 
tude ;  albumin  is  never  absent,  and  the  physical  symp- 


233  bright' S   DISEASE. 

toms,  as  marked  oedema,  vomiting,  or  anasarca,  are  not 
long  in  making  their  appearance.  Unlike  clironic  inter- 
stital  nephritis,  it  is  seldom  chronic  from  the  commence- 
ment, but  is  "usually  traceable  to  some  assignable  cause, 
or  follows  acute  nephritis  ;  it  is  not,  like  the  interstitial 
form,  the  almost  constant  concomitant  of  cystitis  and 
phthisis. 

When  I  speak  of  a  "  cure  "  or  of  recovery,  I  do  not 
mean  that  the  integrity  of  the  kidney  is  absolutely  re- 
stored. Loss  of  epithelia  and  their  replacement  by  en- 
dothelia  must  occur  ;  there  may  be  permanent  atrophy 
of  some  tufts,  some  thickening  of  connective  tissue,  etc., 
but  if  the  kidney  be  left  healthy  enough  to  accomplish 
its  depurative  functions  perfectly,  and  the  inflammatory 
process  be  entirely  arrested,  the  expression  is  exact 
enough. 

Rest  and  Diet. — The  reasons  why  rest  and  the  recum- 
bent position  sometimes  should  be  enjoined  in  chronic 
interstitial  nephritis  apply  equally  in  chronic  croupous 
nephritis. 

The  excretion  of  uric  acid  in  chronic  croupous  ne- 
phritis often  remains  normal,  though  that  of  urea  is 
generally  diminished.  I  believe  it  is  owing  to  the  non- 
retention  of  the  former  that  ursemic  accidents,  as  coma, 
epistaxis,  convulsions,  etc.,  are  less  frequent  than  in 
interstitial  nephritis,  where  the  uric  acid  excreted 
is  diminished.  A  more  highly  nitrogenized  diet  may 
therefore  be  allowed,  and  indeed,  so  great  sometimes  is 
the  quantity  of  albumin  lost  (10  to  20  grains  in  twenty- 
four  hours)  that  its  waste  must  be  supplied,  if  possible, 
by  nitrogenous  food.  The  freedom  of  its  employment 
must  be  regulated  by  the  conditions  of  the  digestive 
system  and  the  tendency  to  ursemic  poisoning. 

Diaphoresis. — What  has  been  said  of  the  importance 
of  this  operation  in  other  forms  of  nephritis  applies  es- 
pecially in  this  one.     ISTot  only  are  the  kidneys  relieved 


CHRONIC   PAUENCIIYMATOUS   JSTEPIIKITIS.  233 

of  the  burden  of  over-separation  and  excretion,  and  the 
calibre  of  its  vessels  diminished,  but  anasarcous  and 
dropsical  conditions  are  often  at  once  relieved  by  it.  I 
can  endorse  Bartels'  opinions  as  to  the  importance  of 
the  sweating  process  : 

' '  In  chronic  parenchymatous  nephritis  also  I  have 
repeatedly  found,  after  the  adoption  of  a  methodical 
diaphoretic  treatment,  that  as  soon  as  I  succeeded  in 
producing  a  profuse  sweat  every  day,  a  more  abundant 
excretion  of  urine  set  in,  and  that  the  percentage  of 
albumin  at  the  same  time  became  reduced.  Rosenstein 
also  has  laid  stress  upon  the  effect  of  diaphoresis  in  in- 
creasing the  urinary  secretion.  In  this  fact  it  seems  to 
me  we  have  evidence  not  only  of  the  symptomatic  but 
also  of  the  curative  value  of  diaphoresis  in  the  treat- 
ment of  chronic  nephritis.  I  have  already  intimated 
my  opinion  as  to  the  manner  in  which  diaphoresis  acts 
on  the  pathological  condition  of  the  kidneys.  I  believe 
that  by  the  long-continued  and  daily  repeated  hyper- 
semia  of  the  capillaries  of  the  skin  the  vessels  of  the 
internal  organs — consequently  those  also  of  the  kidneys 
— are  relieved  of  the  excessive  amount  of  blood  con- 
tained in  them  ;  the  result  of  this  must  necessarily  be 
increased  rapidity  in  the  movement  of  the  blood  through 
the  capillaries  and  veins  which  are  in  a  state  of  inflam- 
matory dilatation.  But  this,  furthermore,  results  in 
increased  secretion,  and  therefore  even  in  this  way 
diaphoresis  acts  antiphlogistically  upon  the  inflamed 
kidnej^s.  In  addition  to  this,  too,  the  profuse  perspira- 
tion depletes  the  general  systemic  circulation,  for  the 
sweat  is  derived  from  the  blood  and  does  not  represent 
a  direct  transudation  of  the  dropsical  fluid.  Now, 
although  the  vessels  promptly  reach  their  former  state 
of  repletion  again  by  the  absorption  of  this  dropsical 
fluid,  still,  it  cannot  be  doubted  that  a  certain  period  of 
time  must  elapse  before   this  is  efllected.    All  this  is 


234  beight's  disease. 

time  gained  for  the  vessels  of  the  inflamed  kidneys — ■ 
time  for  them  to  contract  themselves  to  smaller  cal- 
ibres, and  this  cannot  be  without  its  effect  upon  the 
function  of  these  organs ;  clinical  experience  also  prov- 
ing that  this  effect  is  obtained.  Patients  urinate  more 
freely  just  in  proportion  as  the  circulation,  relieved 
from  obstruction  by  dint  of  the  diaphoresis,  increases 
in  speed,  and  the  urine  contains  less  albumin  in  propor- 
tion as  the  secreting  vessels  lose  their  state  of  preternat- 
ural distention.  Finally,  I  hold  it  to  be  established  that 
the  disturbances  of  nutrition  provoked  by  inflammation 
may  be  completely  set  right  by  a  sufficiently  prolonged 
and  consistent  diaphoretic  treatment." 

If  the  action  of  the  heart  and  strength  permit,  the  hot- 
air,  vapor  bath,  or  wet  blanket  may  be  employed,  as 
described  in  Chapter  XXI.  I  place  them  in  what  I 
think  to  be  the  order  of  their  value.  Pilocarpine,  by 
hypodermic  injection,  and  jaborandi,  can  be  used  if 
necessary.  The  baths  can  be  employed  daily  or  at 
longer  intervals. 

Diuretics  are  more  needed  than  in  chronic  interstitial 
nephritis,  and  are  often  indispensable  to  the  relief  of 
dangerous  conditions,  as  dropsy  of  the  pericardial  sac, 
anasarca,  hydrothorax,  etc.  For  indications  for  their 
use,  etc.,  see  p.  168. 

The  tannate  of  sodium  (see  Chapter  XXI.)  is  suited 
to  some  conditions  of  albuminuria  where  astringent  and 
diuretic  remedies  are  likely  to  be  useful. 

Cormallaria  and  digitalis  are  not  so  often  required  as 
in  interstitial  nephritis,  on  account  of  the  lesser  fre- 
quency of  cardiac  complications ;  but  these  may  fre- 
quently occur,  and  at  all  events  the  diuretic  properties 
of  the  former  are  often  indispensable. 

Nitro-glycerine  (glonoine)  (see  Chapter  XXI.)  has 
proved  of  benefit  in  a  number  of  cases  in  promoting 
diuresis  and  in  diminishing  albuminuria  and  anasarca. 


CHRONIC   PAKENCriYMATOUS   NEPHRITIS.  235 

It  seems  of  use  especially  where  tliere  is  much  arterial 
tension.  I  have  given  it  conjointly  with  the  sesquichlo- 
ride  of  iron,  as  suggested  by  Dr.  Robson. 

Iron  often  proves  of  great  value.  The  following  illus- 
trates its  usefulness : 

Case  XTV. — Mr.  G ,  aged  eighty-one,  six  years  ago  suffered  from 

great  lassitude ;  legs  and  body  began  to  swell ;  urine  found  to  be 
highly  albuminous  ;  had  had  for  a  long  time  a  dull  headache,  becom- 
ing after  a  time  most  intense.  Frequent  micturition  in  small  quan- 
tities ;  nausea  and  vomiting ;  violent  action  of  the  heart  and  intense 
thirst.  This  case  was  pronounced  chronic  parenchymatous  nephritis 
by  one  of  our  most  eminent  physicians,  whose  prognosis  was  that  the 
patient  could  not  possibly  survive  more  than  six  or  twelve. months. 

The  treatment  mainly  employed  was  iron,  quinine, 
alcoholic  stimulants,  and  hot-air  baths,  diuretics  being 
resorted  to  in  limine.     A  liheral  diet  of  animal  food 

toas  ordered.    Mr.  G ,  whom  I  had  known  for  many 

years,  has  given  me  this  account  of  his  case,  which  I  had 
watched  with  interest.  At  the  end  of  three  years  from 
the  commencement  of  treatment  he  was  pronounced 
entirely  cured.  The  kidneys  are  at  present  perfectly 
healthy,  as  I  have  had  an  opportunity  of  ascertaining, 
and  the  patient' s  health  is  now  good. 

The  patient's  constitution,  however,  and  that  of  his 
family  are  remarkably  good,  his  ancestors  being  noted 
for  their  longevity. 

The  treatment  of  this  case  and  of  Case  X.  was  much 
the  same.  The  two  forms  of  nephritis,  however,  dif- 
fered. As  in  that  case,  quinine  was  given,  but  in 
neither  is  it  possible  to  determine  how  important  a  fac- 
tor it  may  have  been  in  relieving  the  kidneys.  There  is 
more  reason  for  supposing,  however,  that  the  iron  had 
a  greater  effect.  As  regards  the  use  of  alcohol,  I  have 
not  found  its  direct  influence  upon  the  kidneys  dele- 
terious.   It  does  have   such  an  influence,   of  course, 


236  bright' S   DISEASE. 

when  used  too  freely,  bat  I  believe  tlie  influence  of  cer- 
tain pure  spirits,  as  gin,  whiskey,  and  brandy,  in  mod- 
eration, dry  champagne,  Rhine  wines,  and  light  claret, 
are  likely  to  have  a  diuretic  and  salutary  effect. 

Arsenic  is  sometimes  of  great  use  in  chronic  croupous 
nephritis.     (See  p.  192.) 

Its  efficacy  is  shown  in 

Case  XY..— J.  P ,  aged  twenty-two  ;  chronic  croupous  nepliritis, 

which  had  existed  six  or  seven  months  at  the  least ;  cause  unknown  ; 
anasarca  of  the  limbs,  nausea,  Yomiting,  headache,  and  debility  ;  uiine 
highly  albuminous,  and  contained  granular  and  hyaline  casts.  The 
ease  was  completely  ciu'ed  by  the  administration  of  Fowler's  solution, 
four  or  fire  drops  after  each  meal,  together  with  the  tincture  of  cin- 
chona, a  drachm  before  each  meal.  The  case  occurred  neaiiy  twenty- 
five  years  ago,  and  I  had  not  then  learned  to  employ  the  bath  for  the 
production  of  diaphoresis.  I  do  not  comment  upon  the  case,  but  sim- 
ply state  it,     I  have  not,  however,  often  found  arsenic  of  great  use. 

The  value  of  the  hitartrate  of  x>otasTi  as  a  diuretic 
in  chronic  croupous  nephritis  is  clearly  shown  in  the 
cases  reported  by  Dr.  J.  Hughes  Bennett  (p.  176).  I 
have  myself  employed  it  with  great  benefit  in  subacute 
and  chronic  croupous  iiephritis. 

The  mild  and  the  corrosive  cTilorides  of  mercury  have 
often  proved  serviceable,  but  much  less  so  tlian  in 
acute  conditions.  For  indications  and  mode  of  use,  see 
Chapter  XXI. 

Cantharides  have  often  been  of  use  in  diminishing 
albuminous  excretion  and  in  promoting  the  secretion 
and  flow  of  urine.  The  efficacy  of  this  remedy  is  often 
greatly  increased  by  combining  it  with  iron. 

Nitric  acid  is  often  of  value,  in  albuminous  and  ana- 
sarcous  conditions,  in  stimulating  the  flow  of  urine  and 
diminishing  albumin.     (See  p.  191.) 

Euonymus  or  its  alkaloid,  euonymine  (see  p.  194), 
may  be  useful  in  torpid  conditions  of  the  liver,  as  is 
also  the  muriate  of  ammonia,  podophyllum,  nitro-mu- 


CHEONIC   PARENCHYMATOUS   NEPHRITIS.  237 

riatic  acid,  etc.  Fitclisin  and  rosaniUn  undoubtedly 
aid  in  diminishing  albuminous  exudation.  Iodide  of 
2yotassium,  unless  in  sypliilitic  conditions,  has  never 
proved  of  much  use  to  me  in  this  form  of  nephritis.  I 
have  found  other  diuretics  more  reliable,  and  this  rem- 
edy has  nearly  always  disappointed  me.  The  experi- 
ence of  Bartels  is  to  the  same  effect. 

Lead. — If  this  remedy  be  of  real  use  in  chronic  ne- 
phritis, its  sphere  should  be  more  in  the  interstitial 
form. 

A  case  is,  however,  reported  by  Prof.  Gatchell,  then 
of  the  University  of  Michigan,  of  what  was  probably 
chronic  or  subacute  interstitial  nephritis  cured  by  lead 
in  conjunction  with  hot-air  baths.  The  cure  may  have 
been  due  to  the  latter,  although  the  experience  of  Le- 
wald  shows  that  lead  can  diminish  albuminuria. 

Lithia  waters  should  also  be  most  useful  in  the  gouty 
kidney,  or  in  nephritis  accompanied  by  the  uric  acid 
diathesis,  but  there  are  certain  conditions  of  deranged 
digestion,  ansemia,  etc.,  even  in  croupous  nephritis, 
which  would  not  be  likely  to  be  benefited  by  them.  The 
mineral  w^aters  enumerated  in  the  chapter  on  Chronic 
Interstitial  Nephritis  are  here  applicable,  on  the  same 
principles  as  there  mentioned. 


CHAPTER  XXY. 

-     -        TREATMENT  OF  SUPPURATIVE  NEPHRITIS. 

When  acute  suppurative  nephritis  can  be  diagnosti- 
cated as  an  accompaniment  of  and  caused  by  acute 
nephritis,  if  the  abscesses  are  small,  recovery  may 
take  place  with  the  recovery  of  the  latter,  and  this 
often  occurs  when  the  nephritis  is  the  result  of  scar- 
latina or  diphtheria.  When  it  has  this  causology  the 
treatment  must  be  that  of  the  acute  nephritis.  -  When 
it  arises  from  blood-poisoning,  the  former  of  course 
must  receive  due  consideration,  but,  at  the  same  time, 
it  must  be  remembered  that  with  the  suppuration  there 
is  more  or  less  diffused  nephritis,  and  such  treatment 
as  is  likely  to  help  this  should  be  employed;  indeed, 
this  latter  condition,  with  its  treatment,  should  always 
be  considered.  When  caused  by  calculi  or  cystitis,  of 
course  these  must  be  removed  or  cured  if  possible; 
but  it  must  always  be  borne  in  mind,  unless  evidence 
of  disorganization  or  extensive  suppuration  exist,  that 
often  the  abscesses  affect  only  one  kidney,  that  they  are 
often  small  and  circumscribed,  and  may  heal  up,  the 
liquid  contents  of  the  small  ones  being  absorbed,  the 
rest  being  converted  into  a  calcareous  mass.  Sometimes 
the  abscess  may  empty  into  the  pelvis  of  the  kidney. 

When  the  abscesses  open  into  the  peritoneal  viscera, 
or  into  the  groin,  the  proper  methods  of  evacuation  must 
be  employed.  Extirpation  of  the  kidney  has  been  fre- 
quently successfully  XDerformed  in  sup^Durative  nephritis 
jDroduced  by  nephritic  calculus,  and  from  other  causes. 


APPENDIX. 


{a)  More  extended  trials  lead  me  to  consider  the 
brine  test  a  more  sensitive  one  than  the  nitric  acid. 

{b)  When  a  proper  light  is  not  otherwise  attainable, 
I  find  a  kerosene  or  oil  lamp  with  a  large  flame  per- 
fectly satisfactory. 

(c)  A  case  so  forcibly  illustrating  the  correctness  of 
the  views  I  present  in  the  above  chapter  relative  to  the 
long  existence  that  nephritis  may  have  without  albu- 
minuria, is  at  this  moment,  October  22, 1883,  under  my 
care,  and  I  insert  it  here. 

It  is  that  of  a  gentleman  fifty-four  years  of  age,  of  an 
excellent  constitution  ;  his  strength  has  been  somewhat 
impaired  for  about  three  years,  and  he  has  suffered  from 
dyspepsia,  headaches,  and  debility.  For  two  years 
previous  to  last  spring  I  made  examinations  of  the 
urine  every  three  or  four  weeks,  with  the  invariable  re- 
sult of  finding  epithelia  from  the  kidney,  pus,  and  some- 
times blood  corpuscles.  No  albumin  could  ever  be  dis- 
covered. 

From  May  to  October  1st  the  patient  was  absent 
from  the  country.  Since  October  1st  I  have  several 
times  examined  the  urine,  and  have  each  time  found 
from  one-half  to  three-fourths  of  one  per  cent,  of  al- 
bumin. The  microscopic  appearances  remain  the  same, 
and  various  symptoms  of  nephritis  have  become  mani- 
fest. 


INDEX. 


Albumin,  source  and  secretion  of,  46 

absence  of,  in  interstitial  nephritis  and  cirrhosis,  146 
intermittence  of,  in  interstitial  nei^hritis,  133 
physiological,  39 
testing  for,  49 

by  heat,  49 

nitric  acid,  50 

brine,  52 

picric  acid,  53 

the  double  iodide  of  mercury  and  potassium. 

(Tanret's  test),  55 
sodium  tungstate,  57 
ferrocyanide  of  potassium,  58 
test  papers,  58 
behavior  of,  with  the  various  reagents,  60 
Albuminuria  occurring  in  health,  39 

after  food,  39 
after  rest  and  fatigue,  41 
after  severe  brain  work,  42 
from  cold  bathing,  42 
from  reflex  action,  42 
in  healthy  children,  40 
as  a  result  of  various  derangements  of  the  health,  44 
Alcoholic  beverages  in  the  treatment  of  nei^hritis,  209 
Alcohol  as  a  factor  in  the  i^roduction  of  nephritis,  124,  125 
Anaesthetics,  danger  from,  in  nephritis,  230 
Apis  melliflca  in  the  treatment  of  nephritis,  193 
Appendix,  239 

Arsenic  in  the  treatment  of  nephritis,  192 

Arteries,  atheroma  and  changes  of,  in  interstitial  nephritis,  135 
16 


242  INDEX. 

Baths,  hot  aii-  and  vapor,  in  the  treatment  of  nephritis,  164,  209 
Bleeding,  local,  in  acute  nephritis,  180 

in  ursemic  convulsions,  196 
Bright's  disease,  as  understood  by  Bright  himself,  76 
and  nephritis,  nomenclature  of,  76,  77 

CAiiOMEL  in  the  treatment  of  nephritis,  186,  212 
Cantharides  in  the  treatment  of  nephritis,  190,  223 

X)athological  effects  upon  the  kidney  of,  190 
Capsule,  Bowman's,  2 

changes  of,  in  chronic  croupous  nephritis,  111 
Casts,  directions  for  examining  the  urine  for,  73 

importance  and  significance  of,  61 

diagnosis  of  mucous  and  hyaline,  63 

nature  and  formation  of,  65 

formed  at  the  expense  of  the  ej)ithelia,  68 

forms  and  varieties  of,  71 

formation  of,  in  chronic  croupous  nephritis,  107 
Cirrhosis,  renal,  159 
Cirrhosis  "without  albumin,  146 

Climatic  resoris  in  chronic  interstitial  nephritis,  206 
Chloral  in  uraemic  convulsions,  196 
Counter-initants  in  acute  nephritis,  179 
Convallaria  majaUs,  its  uses,  history,  etc.,  171 
in  nephritis,  171,  220,  234 
Corrosive  sublimate,  pathological  effects  upon  the  kidneys,  189 

in  nephritis,  186,  236 
Cysts,  mode  of  formation,  112 

Diaphoresis  in  nephritis,  164,  232 
Digitalis  in  nephritis,  170,  221,  234 
Diet  in  nephritis,  164,  209,  232 
Diuretics  in  nephritis,  164,  168,  229,  234 

modus  operandi  of,  176 

saline  and  alkaline  in  nephritis,  176,  230 
Dropsy,  absence  of,  in  interstitial  nephritis,  138 

EpitheiiIA,  varieties  of,  in  the  kidneys,  6 

rod-like  structru-e,  reticulum,  and  minute  anatomy  of,  7 
of,  in  inflammation,  14 
animals,  11 


INDEX.  243 

Epitlielia,  cloudy  swelling  of,  15,  87 

in  the  formation  of  casts,  68 

of  the  kidney,  in  diagnosis  of  nephritis,  150 

how  to  examine  the  urine  for,  73 

Endothelia  of  the  tubules,  18 

Ergot  in  the  treatment  of  nephritis,  182 

Euonymus  atropuriDurens  in  the  treatment  of  neiahritis,  194,  236 


FucHSiN  in  the  treatment  of  nephritis,  182 

Gallic  acid  in  the  treatment  of  nephritis,  182 

Glonoine  in  the  treatment  of  nephi-itis  (see  nitro-giycerine). 

Gold,  chloride  of,  in  the  treatment  of  nephritis,  220 

Gold  and  soda,  chloride  of,  in  the  treatment  of  nephritis,  220 

Glomerulus,  the,  2 

functions  of,  29 

Helonias  in  the  treatment  of  nephritis,  193 

Ikon,  chloride,  in  the  treatment  of  nephritis,  181,  221,  235 


Jabokandi  in  the  treatment  of  nephritis,  167 
Juniper  as  a  diuretic,  230 


Kidney,  atroxDhy  of,  117 

general  anatomy  of,  1 

circulation  of,  23 

connective  tissue  of,  23 

cirrhotic,  the,  127 

epithelia,  varieties  of,  in,  6 

granular  degeneration  of,  117 

gouty  and  cirrhotic,  127 

impermeability  of,  to  uric  acid  in  gout,  126 

as  affected  by  lead  jpoisoning,  128,  129 

tubules  of,  2 

waxy  degeneration  of,  108 

zones  of,  1 


244  INDEX. 

Lead  in  the  treatment  of  nephritis,  237 

poisoning  as  a  cause  of  interstitial  nephritis,  128 

pathological  effects  upon  the  kidney,  128 

producing  gout,  131 

interrupting  the  excretion  of  uric  acid,  131 

Medullaby  rays,  3 

Muriate  ammonia  in  the  treatment  of  nephritis,  195 

Mineral  waters,  value  of,  in  nephritis,  and  authoi-ities,  228,  229 

Mineral  waters  in  the  treatment  of  nephritis,  224 

Carlsbad,  224 

Buffalo  Lithia,  224 

Bilin,  226 

Ballston,  226 

Contrexeville,  226 

Pougues,  226 

Franzenbad,  227 

Tarasp,  227 

St.  Nectaire,  227 

Mt.  Dore,  227 

Kreutznach,  228 

Saratoga  waters,  228 

Wildungen,  228 

Marienbad,  228 

Nephbitis,  75 

varieties  of,  77 

no  exclusive  parenchymatous,  nor  interstitial,  77 

croupous,  79 

synonyms,  79 
acute  croupous,  definition  of,  79 
diagnosis  of,  85 
course  and  prognosis  of,  85 
pathology  of,  86 
etiology  of,  80 
from  irritants,  82 
malaria,  82 
treatment  of,  163 
chronic  croupous,  92 

synonyms,  92 
curability  of,  231 


INDEX.  .  245 

Nephritis,  cliroiiic  croupous,  etiology,  92 

ages  wlieri  most  frequent,  96 
course  and  prognosis,  101 
diagnosis,  100 
pathology,  103 
pregnancy  as  a  cause  of,  96 
treatment  of,  231 
interstitial,  117 
catarrhal,  117 
interstitial,  synonyms,  117 

nature  and  nomenclature  of,  117 

general  pathological  and  histological  changes 

in,  118 
acute  and  chronic,  119 
curability  of,  210 
general  etiology  of,  119 
caused  by  cold,  121 
gout,  126 
syphilis,  125 
lead  poisoning,  129 
pregnancy,  130 
cystitis,  131 

valvular  disease  of  the  heart,  132 
among  painters  and  workers  in  lead,  129,  130 
ages  when  most  frequent,  120 
comparative  prevalence  in  the  sexes,  121 
duration  of,  155 
diagnosis  of,  100 
heredity  of,  122 

hemorrhagic  attacks  in,  134,  135 
polyuria  in,  134 

heart,  hypertrophy  of,  in,  135,  137 
headaches  in,  131,  138 

nitro-glycerine  in  treatment  of,  188,  220,  234 
nitric  acid  in  treatment  of,  191,  222,  236 
without  albuminuria,  141 
prognosis  of,  155 
pathology,  156 
treatment  of,  205 
suppurative,  114 

diagnosis  of,  116 

course  and  prognosis  of,  116 


246  INDEX. 

Nephritis,  suppurative,  etiology  and  pathology  of,  114 
treatment  of,  238 

Opium  in  ursemic  convulsions,  196 

PiLOCAKPiNE  in  the  treatment  of  nephritis,  167 
Phosphoric  acid  in  ursemic  convulsions,  192,  222 
Polyuria  in  interstitial  nephritis,  134 
Potassse  bitart.  in  nephritis,  176,  236 
Pregnancy  as  a  cause  of  nephritis,  96,  130 

Eest  in  the  treatment  of  nephritis,  163,  222 

Eosaniline  in  the  treatment  of  nephritis,  182 

Eetinitis,  albuminous,  in  chronic  interstitial  nephritis,  135 

Eetinal  changes  in  chronic  interstitial  nephritis,  137 

Eod-like  epithelia,  functions  of,  in  urinary  secretion,  34,  35 

ScoPABius  as  a  diuretic,  175 

Tannate  of  sodium  in  nephritis,  183,  220,  234 
Tufts,  Malpighian,  description  of,  2 

changes  in,  in  chronic  croupous  nephritis.  111 
Turpentine  in  nephritis,  220 

UKiEMic  accidents  in  interstitial  nephritis,  134,  138,  140 

treatment  of,  230 
Urea  and  uric  acid,  excretion  of,  in  interstitial  nephritis,  134,  138 

interrupted  by  lead,  130 
Urine,  nature  and  sources  of,  29 

Ludwig's  theory  of  the  secretion  of,  30 

experiments  of  Overbeck,  Heidenhain  and  others,  illustrating, 
30 
Urinary  extractives  and  urine,  rod-like  ej)ithelia  and  tube  system  in 
formation  of,  34,  35 

Vasa  afferantia,  2 

Vasa  efferantia,  2 

Vasa  recta,  25 

Vision,  disturbances  of,  in  interstitial  nephritis,  137 


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